Chapter 60 - Assessment of Neurologic Function

4. A nurse is performing a complex neurological assessment on a client recently diagnosed with Alzheimer disease. What question should the nurse anticipate to ask when assessing the client's language ability?

"Can you write your name on this blank sheet of paper?"

9. The nurse is admitting a client to the unit who is diagnosed with a lower motor neuron lesion. What entry in the client's electronic record is most consistent with this diagnosis?

"Client demonstrates an absence of deep tendon reflexes."

13. A 26-year-old female client, who is breastfeeding a newborn, is due to undergo a computed tomography (CT) scan with dye contrast. What instruction should the nurse provide to the client based on this procedure?

"Stop breastfeeding for the time frame given by the provider within the nuclear medicine department."

31. A client for whom the nurse is caring has positron emission tomography (PET) scheduled. In preparation, what should the nurse explain to the client?

"The test may result in dizziness or lightheadedness."

30. A client is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the client in preparation for this test?

"You will need to lie still throughout the procedure."

20. The nurse is planning the care of a client with Parkinson disease. The nurse should be aware that treatment will focus on what pathophysiologic phenomenon?

-Decreased availability of dopamine

21. A client is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this client, the nurse has the client stick out the tongue and move it back and forth. What is the nurse assessing?

-Function of the hypoglossal nerve

19. A client in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows the brain regulates body temperature in which of the following areas?

-Hypothalamus

17. A client is having a "fight or flight response" after receiving a bad disease prognosis. What affect will this have on the client's sympathetic nervous system?

-Increase in the secretion of sweat

22. A trauma client was admitted to the intensive care unit (ICU) with a brain injury that resulted in a change in level of consciousness and altered vital signs. The client subsequently became diaphoretic and agitated. The nurse should recognize which of the following syndromes as the most plausible cause of these symptoms?

-Sympathetic storm

16. A health care provider has prescribed a standard electroencephalogram (EEG) test for the client. What general instructions should the nurse provide to the client? Select all that apply

-The procedure generally takes 45 to 60 minutes. -This procedure uses a water-soluble lubricant for electrode contact which can be easily wiped off and removed using shampoo -Please refrain from drinking coffee and any caffeinated beverages the morning prior to the procedure

23. The nurse is preparing to assess a client with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply.

-Understanding of the tests used to diagnose neurologic disorders -Knowledge of nursing interventions related to assessment and diagnostic testing -Knowledge of the anatomy of the nervous system

18. In which specific instances should the nurse assess the client's cranial nerves? Select all that apply.

-When level of consciousness is decreased -With brain stem pathology -In the presence of peripheral nervous system disease

34. A client had a lumbar puncture performed at the outpatient clinic and the nurse phoned the client and family that evening. What does this phone call enable the nurse to determine? Select all that apply.

-Whether the client has had any complications from the test. -The necessary steps for the client and family to take should complications arise.

10. An older adult client is being discharged home. The client lives alone and has atrophy of the olfactory organs. The nurse tells the client's family that it is essential that the client have what installed in the home?

A smoke detector

26. The nurse caring for an 80-year-old client knows that the client has a preexisting history of dulled tactile sensation. The nurse should first consider what possible cause for this client's diminished tactile sensation?

Age-related neurologic changes

36. The nurse is performing a neurologic assessment of a client whose injuries have rendered the client unable to follow verbal commands. How should the nurse proceed with assessing the client's level of consciousness (LOC)?

Assess the client's eye opening and response to stimuli.

35. A client is currently being stimulated by the parasympathetic nervous system. What effect will this nervous stimulation have on the client's bladder?

Bladder contract

5. A nurse is assessing reflexes in a client with hyperactive reflexes. When the client's foot is abruptly dorsiflexed, it continues to "beat" two to three times before settling into a resting position. How should the nurse document this finding?

Clonus

15. A client is being given a medication that stimulates the parasympathetic system. Following administration of this medication, the nurse should anticipate what effect?

Constricted pupils

33. The health care provider has prescribed a somatosensory evoked responses (SERs) test for a client for whom the nurse is caring. The nurse is justified in suspecting that this client may have a history of what type of neurologic disorder?

Demyelinating disease

39. During the performance of the Romberg test, the nurse observes that the client sways slightly. What is the nurse's most appropriate action? C. Document successful completion of the assessment.

Document successful completion of the assessment.

29. A trauma client in the ICU has been declared brain dead. What diagnostic test is used in making the best determination that the brain's electrical activity has ceased?

Electroencephalography (EEG)

1. A nurse is performing a neurological assessment on a client at home. During the assessment, the nurse notices that the client has a flat affect. Which lobe of the brain is responsible for a person's affect?

Frontal lobe

38. The neurologic nurse is testing the function of a client's cerebellum and basal ganglia. What action will most accurately test these structures?

Guide the client through the performance of rapid, alternating movements

14. What neurologic assessment should the nurse perform to gauge the client's function of cranial nerve I?

Have the client identify familiar odors with the eyes closed.

28. A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution?

Hot or cold packs

40. The nurse is providing information to a client about neurological disorders associated with genetic defects. The nurse knows which disease is considered an autosomal dominant disorder?

Huntington disease

25. A client has been recently diagnosed with myasthenia gravis. Which is indicative of a person diagnosed with myasthenia gravis?

Impairment of acetylcholine binding to muscle cells

11. The nurse is conducting a focused neurologic assessment and is assessing the client's gag reflex. How should the nurse best perform this aspect of the assessment?

Lightly touch the client's pharynx with a cotton swab.

8. The nurse is caring for a client with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the client's neurologic assessment?

Loss of voluntary control of movement

32. A client is scheduled for a myelogram, and the nurse explains to the client that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests?

Lumbar puncture

37. In the course of a focused neurologic assessment, the nurse is palpating the client's major muscle groups at rest and during passive movement. Data gleaned from this assessment will allow the nurse to describe which of the following aspects of neurologic function?

Muscle tone

24. When caring for a client with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would most likely elicit a response from cranial nerve VII?

Observe for facial movement symmetry, such as a smile.

6. The nurse is doing an initial assessment on a client newly admitted to the unit with a diagnosis of cerebrovascular disease. The client has difficulty copying a figure that the nurse has drawn and is diagnosed with visual receptive aphasia. What brain region is primarily involved in this client's deficit?

Parietal-occipital area

12. When assessing a 36-year-old male, the nurse gently strokes the client's right palm using a cotton applicator. As the nurse strokes the client's palm the nurse then checks to see if the client will begin to grasp the applicator. This assessment is associated with which of the following reflexes?

Pathologic

7. What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brain's surface?

Pia mater

3. A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-related changes that may influence the assessment results. Of what phenomenon should the nurse be aware?

Reduction in cerebral blood flow

2. A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize what action?

Removing all metal-containing objects

27. A 72-year-old man has been brought to his primary care provider by the client's daughter, who claims that the client has been experiencing uncharacteristic lapses in memory. What principle should underlie the nurse's assessment and management of this client?

Thorough assessment is necessary because changes in cognition are always considered to be pathologic.