HA - Prep U Neuro
The nurse is preparing to test the sensory cranial nerves. The nerves being tested include (Select all that apply.)
olfactory, optic and acoustic
Sensations of temperature, pain, and crude and light touch are carried by way of the
spinothalamic tract. Explanation: Sensations of pain, temperature, and crude and light touch travel by way of the spinothalamic tract.
The nurse is assessing an older adult client when the client tells the nurse that she has experienced transient blind spots for the last few days. The nurse should refer the client to a physician for possible
stroke. Explanation: Transient blind spots may be an early sign of a cerebrovascular accident (CVA).
Which of the following would the nurse expect to assess if a client has a lesion of the sympathetic nervous system?
Constricted pupil unresponsive to light Explanation: A constricted pupil unresponsive to light or accommodation suggests a lesion of the sympathetic nervous system. Sympathetic nervous system stimulation would lead to bilateral dilated pupils. A unilaterally dilated pupil unresponsive to light or accommodation would suggest damage to cranial nerve III. Argyll Robertson pupils are associated with central nervous system syphilis, meningitis, brain tumor, or alcoholism.
The client presents at the clinic with a complaint of weakness that is made worse with repeated effort and improves with rest. The client's complaint is consistent with what health problem?
Myasthenia gravis Explanation: Weakness made worse with repeated effort and improved with rest suggests myasthenia gravis.
When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding?
Uvula and soft palate rising bilaterally Explan: Normal findings associated with testing CN IX and CN X include a uvula and soft palate rising bilaterally and symmetrically on phonation. A stationary or asymmetrical soft palate or deviation of the uvula would be considered an abnormal finding.
The nurse performs the action shown when assessing a client. Which cranial nerve is the nurse assessing in this client?
V Explanation: Assessing for corneal reflex tests the sensory function of cranial nerve V. Cranial nerve II is assessed by using the Snellen chart. Cranial nerves III and IV are assessed with the use of extraocular movements and pupil response to light and accommodation.
Which of the following assessment techniques should the nurse use to determine a client's stereognosis?
With the client's eyes closed, place a coin or key in hand and ask him or her to identify the object. Explanation: Stereognosis is the ability to identify a familiar object by feeling it. It is tested by placing an object in the client's hand for identification while he or she has the eyes closed. The other assessment techniques assess for number identification, two-point discrimination, and point localization.
A client presents to the health care facility for a routine health checkup. The nurse learns that the client has a long history of cardiovascular disease, including hypertension and carotid artery disease. When assessing this client for potential problems in the nervous system, which question by the nurse is appropriate?
"Are you having any dizziness or lightheadedness?" Explanation: Clients with carotid artery disease may experience dizziness or lightheadedness, especially with ambulation because of the increased difficulty in circulating enough blood and oxygen to the brain. Trouble hearing and changes in vision may signal cranial nerve dysfunction. Weakness in the muscles of the extremities is an indication of a CVA or nerve injury.
What instruction should a nurse give a client when having trouble eliciting a response from testing the patellar deep tendon reflex?
"Place your hands together, lock your fingers, and squeeze." Explanation: If deep tendon reflexes are diminished or absent, a reinforcement technique may be used to enhance the client's response. When testing the leg reflexes, have the client interlock the hands and squeeze. Closing the eyes and tightening the thigh muscles of the opposite leg will not aid in eliciting a reflex response. Clenching the teeth is a reinforcement technique that is helpful to elicit a response when assessing the arm reflexes.
When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as being at highest risk?
68-year-old African American male with hypertension Explanation: Risk factors include older adulthood (risk doubling each decade after age 55), male sex, African American race, hypertension, smoking, chronic alcohol intake (more than three drinks per day), and sleep apnea among others. In the clients listed, the 68-year-old African American male with hypertension has the greatest risk due to his age, race, and hypertension. The other clients would be at risk, but the risk would be less.
The glossopharyngeal nerve contains sensory fibers for taste on posterior third of tongue and sensory fibers of the pharynx that result in the gag reflex when stimulated.
Abdominal Explanation: Abdominal reflexes are assessed by lightly stroking the abdomen on each side, above and below the umbilicus. This evaluates the function of the spinal levels T8-T10 with the upper abdominal reflex and spinal levels T10-T12 with the lower abdominal reflex. The sole of the foot is stroked to assess for the presence of the Babinski reflex. The inner thigh is stroked when assessing the cremasteric reflex in a male client. The ankle is dorsiflexed when assessing for ankle clonus.
The nurse is assessing a 39-year-old woman who has a 20-year history of cigarette smoking. When reviewing the client's current medication administration record, what drug would the nurse identify as increasing the woman's risk of stroke?
An oral contraceptive Explanation:The use of oral contraceptives, especially in smokers over 35, constitutes a significant risk factor for stroke. Acetaminophen, ASA, and beta blockers usually decrease an individual's risk of stroke.
The nurse has completed a Glasgow Coma Scale assessment and assigns the client a score of three. Which is the best way for the nurse to assess pain in this client?
Assess for nonverbal signs Explanation: The GCS is a tool for assessing a patient's response to stimuli. Scores range from 3 (deep coma) to 15 (normal). Eye opening response: Spontaneous 4 To voice 3 To pain 2 None 1 Best verbal response: Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 None 1 Best motor response: Obeys command 6 Localizes pain 5 Withdraws 4 Flexion 3 Extension 2 None 1 Total 3-15. A score of three indicates deep coma; therefore, the client is unable to verbalize pain level on numerical scale or FACES scale. A client in a coma can still experience pain.
The nurse is assessing an newly admitted client with a seizure disorder. The nurse would asses the client for what?
Aura Explanation: The nurse should assess the client about an aura that forewarns the client of an impending seizure. Lightheadness, hallucinations and delusions are not associated with seizures.
As adults age, peripheral nerve function and impulse conduction decrease. What is the result of this decrease?
Decreased proprioception Explanation: In older people peripheral nerve function and impulse conduction decreases with resultant decreased proprioception and potential for a Parkinson-like gait.
When assessing deep tendon reflexes in an elderly client what finding would the nurse anticipate?
Decreased reaction time Explanation: Older clients usually have deep tendon reflexes intact, although a decrease in reaction time may slow the response.
A client has a disorder of the hypothalamus. The nurse recognizes that this structure is found in which area of the brain?
Diencephalon
A nurse performs a neurologic examination on a client who sustained an injury to the spinal cord. What finding should the nurse expect when stroking the bottom of the client's feet?
Dorsiflexion of the great toe and fanning of all toes Explanation: An injury to the spinal cord or the brain causes abnormal posturing in the client. This includes dorsiflexion of the great toe and fanning of all toes when the sole of the foot is stroked—a positive Babinski reflex—which is normal in newborns but in adults is an indication of lesions of upper motor neurons or unconscious states resulting from drug and alcohol intoxication, brain injury, or subsequent to an epileptic seizure. In the normal adult, the response to stroking the bottom of the foot is flexion of the toes. Dorsiflexion and plantar flexion are not associated with this reflex.
When preparing to test a client for meningeal irritation, what would the nurse to do first?
Ensure no injury to the cervical spine Explanation: Before testing a client for meningeal irritation, the nurse needs to ensure that there is no injury to cervical vertebrae or the cervical cord. Otherwise further injury could occur because testing involves flexing the neck. It is not necessary to check for fever or chills or a Babinski reflex. The client is positioned supine for these tests.
During assessment, the nurse notes the client has limited movement of his lower extremities and sways when standing with feet together. The nurse identifies that the client is at risk for what?
Falls Explanation: The client is at risk for falls due to impaired mobility and decreased movement of his lower extremities. There is no evidence to support the client is at risk for a stroke or pressure ulcers.
A client who was injured by a fall at a construction site has been admitted to the hospital. He has suffered nerve damage such that his gag reflex is no longer intact, requiring him to receive intravenous total parenteral nutrition. Which nerve should the nurse suspect to be involved in this client's injury?
Glossopharyngeal (IX) Explanation: The glossopharyngeal nerve (cranial nerve IX) contains sensory fibers for taste on posterior third of tongue and sensory fibers of the pharynx that result in the "gag reflex" when stimulated. The vagus nerve (cranial nerve X) carries sensations from the throat, larynx, heart, lungs, bronchi, gastrointestinal tract, and abdominal viscera and promotes swallowing, talking, and production of digestive juices. The spinal accessory nerve (cranial nerve XI) innervates neck muscles (sternocleidomastoid and trapezius) that promote movement of the shoulders and head rotation and promotes some movement of the larynx. The hypoglossal nerve (cranial nerve XII) innervates tongue muscles that promote the movement of food and talking.
A client is admitted to the health care facility with new onset of right-sided paralysis, slurred speech, and lethargy. A nurse obtains in the history that the client has uncontrolled hypertension and smokes 2 packs of cigarettes a day. Which nursing diagnosis is priority for the client upon admission?
Risk for Aspiration Explanation: Due to the client's decreased mental status and slurred speech, he is at greatest risk for aspiration. Measures must be implemented by the nurse to prevent aspiration, such as NPO, elevating the head of bed, and assessment of lung sounds. Impaired Verbal Communication is a psychosocial issue, and physiologic problems take precedence over mental health at this point in time. Unilateral neglect is not as much of a priority as is the risk for aspiration. There is no indication that there is a risk for altered skin integrity.
An adult client has asked the nurse about actions that she can take to reduce her future risk of stroke. What health promotion activity should the nurse prioritize?
Smoking cessation Explanation: Smoking is a major risk factor for stroke, and clients should be encouraged to quit. Screening with diagnostic imaging is not currently recommended. Impaired coping is not a significant risk factor. A healthy diet reduces the risks of stroke, but supplements may or may not be required.
The diencephalon of the brain consists of the
thalamus and hypothalamus. Explanation: The diencephalon lies beneath the cerebral hemispheres and consists of the thalamus and hypothalamus.
The nurse is planning to test position sensation in an adult female client. To perform this procedure, the nurse should ask the client to close her eyes while the nurse moves the client's
toes up or down. Explanation: Test sensitivity to position. Ask the client to close both eyes. Then hold the client's toe or a finger on the lateral sides and move it up or down. Ask the client to tell you the direction it is moved. Repeat on the other side.
When examining the eye, the nurse notices difficulty with downward motion. The nurse understands that which cranial nerve is involved?
trochlear Explanation: The trochlear nerve controls inferomedial eye movement.
Which of the following is usually the first sign of neurological deterioration?
Altered mentation and decreasing level of consciousness Explanation: Altered mentation and decreasing level of consciousness are usually the first signs of neurological deterioration. Nurses should be alert to even subtle changes in the client's behavior and level of responsiveness. With unilateral herniation, an ipsilateral (same-sided) dilating pupil, at first sluggishly reactive, may signify neurological worsening. As herniation progresses, which it may do rapidly, response only to pain, contralateral (opposite-sided) posturing of extremities, and brainstem abnormalities may be noticeable. With bilateral herniation, pupil change and reflex posturing are on both sides.
On assessment of a client, the nurse finds that the client has difficulty in producing and understanding language. How should the nurse document this finding in the client's record?
Aphasia Explanation: The nurse should document difficulty in producing and understanding language as aphasia. Dysarthria is the defect in muscular control of speech caused by lesions of the nervous system, Parkinson's disease, or cerebral disease. Dysphonia is the voice volume disorder caused by laryngeal disorder or impairment of cranial nerve X. Speech apraxia also known as dyspraxia, is a speech disorder in which a person has trouble saying what he or she wants to say correctly and consistently.
A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. What would the nurse do?
Ask a client to identify scents. Explanation: Cranial nerve I is the olfactory nerve, which is tested by having the client occlude one nostril and identify a scent. Using the Snellen chart tests CN II, the optic nerve. Testing extraocular eye movements evaluates CN III (oculomotor), CN IV (trochlear), and CN VI (abducens). The Weber test evaluates CN VIII (acoustic/vestibulocochlear).
A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. Which of the following would the nurse do?
Ask a client to identify scents. Explanation: Cranial nerve I is the olfactory nerve, which would be tested by having the client occlude one nostril and identify a scent. Using the Snellen chart tests CN II, the optic nerve. Testing extraocular eye movements evaluates tests CN III (oculomotor), CN IV (trochlear), and CN VI (abducens). The Weber test evaluates CN VIII (acoustic/vestibulocochlear).
A nurse is testing a client's corneal reflex but notices that the reflex appears to be reduced. The client is otherwise alert and oriented with no signs of neurological degeneration. What is an appropriate action by the nurse?
Ask the client about the presence of a contact lens Explanation: The corneal reflex test is done to assess the sensory portion of cranial nerve V (facial). If the client has an intact nervous system, the nurse should ask about the presence of a contact lens because they can cause the reflex to be absent or reduced. Touching the cornea with a small piece of cotton is how the test is performed. Blinking or rinsing the eyes are not appropriate actions.
A client reports the feeling of being unsteady when walking. What is an appropriate action by a nurse to assess for a problem with gait and balance?
Ask the client to walk in a heel to toe fashion and watch for an unsteady gait Explanation: To assess the presence of an unsteady gait, the nurse should ask the client to walk in a heel to toe fashion and watch for an unsteady gait. This is called tandem walking. Having the client stretch out the arms and bring one finger at a time to the nose test for coordination. A normal gait should be steady with the opposite arm swinging as the client walks. Telling the client to stand with arms at the sides a note the presence of swaying is the Romberg test which test for balance but does not assess the client's gait.
A nurse is preparing to assess a client's cerebellar function. What aspect of neurological function should the nurse address?
Balance Explanation: Balance and coordination are functions of the pyramidal and extrapyramidal tracts of the motor and cerebellar systems. Remote memory and mental status exam provide information about the client's cognitive ability. Testing for sensation would address issues with specific cranial nerves or problems involving the parietal lobe.
A nurse is preparing to assess a client's cerebellar function. Which of the following would the nurse expect to test?
Balance Explanation: Balance and coordination are functions of the pyramidal and extrapyramidal tracts of the motor and cerebellar systems. Remote memory and mental status exam provide information about the client's cognitive ability. Testing for sensation would address issues with specific cranial nerves or problems involving the parietal lobe.
The nurse has positioned a client supine and asked her to perform the heel-to-shin test. An inability to run each heel smoothly down each shin should prompt the nurse to perform further assessment in what domain?
Balance and coordination Explanation: Deviation of the heel to one side or the other during the heel-to-shin test may be seen in cerebellar disease. As such, further assessment of balance and coordination is likely indicated. This assessment finding is not suggestive of deficits in reflexes, sensation, or strength.
During the health history a client reports a decrease in his ability to smell. During the physical assessment, the nurse would make sure to assess which cranial nerve?
CN I Explanation: CN I (olfactory) would be evaluated to determine if the client was experiencing a problem here related to his report of a decrease in smell. Evaluation of CN II (optic) would be indicated if the client reported changes in vision. Evaluation of CN VII (facial) or IX (hypoglossal) would be indicated if the client reported a decrease in his ability to taste.
The brain is a network of interconnecting neurons that control and integrate the body's activities. What components make up these neurons? Select all that apply.
Cell body, Axon and Dendrite Explan: Each neuron contains a cell body , which serves as the control center; smaller receiving fibers called dendrites; and a connecting long fiber called an axon. Axons are white because they are covered with a myelin sheath that speeds up impulse conduction. Cell bodies are on the outside of the brain (gray matter or cerebral cortex), while axons that connect to other parts of the nervous system are directed toward the center of the brain.
During the Romberg test, a client is unable to stand with his feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would identify this as which of the following?
Cerebellar ataxia A wide-based, staggering, unsteady gait and positive Romberg test (client unable to stand with feet together) suggest cerebellar ataxia. Spastic hemiparesis is characterized by a flexed arm held close to the body while the client drags the toes of the leg or circles it stiffly outward and forward. A Parkinsonian gait is a shuffling gait. A scissors gait is a short stiff gait with the thighs overlapping each other with each step.
A nurse observes a client's gait and notes it to be wide based and staggering. The Romberg test results were positive. The nurse recognizes this as what type of abnormal gait?
Cerebellar ataxia Explanation: Cerebellar ataxia is recognized by the wide-based and staggering gait. The Romberg test will be positive. This gait can be seen in persons with cerebellar disease or alcohol or drug intoxication. The characteristic abnormality in Parkinson's disease is the shuffling gait with a stooped-over posture and flexion of the hips and knees. Spastic hemiparesis presents with the arm flexed and held close to the body while the client drags the toes and circles the leg outward and forward. Footdrop is seen when the client lifts the foot and knee high with each step, then slaps the foot hard to the ground.
The nurse is assessing the client's coordination and finds that her movements are clumsy, unsteady, and inappropriately varying in their speed, force, and direction. The nurse notes that patient has dysmetria. What would the nurse know this patient has?
Cerebellar disease Explanation: In cerebellar disease, movements are clumsy, unsteady, and inappropriately varying in their speed, force, and direction. The finger may initially overshoot its mark, but finally reaches it fairly well, termed dysmetria. An intention tremor may appear toward the end of the movement.
The husband of a 65-year-old female tells the nurse, "My wife is having trouble navigating the steps in our home and she needs my help to step down off a curb." What part of the nervous system should the nurse assess for a potential source of the problem?
Cerebellum Explanation: The part of the nervous system that controls the body's ability to move the muscles and maintain balance is the motor and cerebellar systems. The temporal lobe is part of the cerebrum and helps with receiving and interpreting impulses from the ear. The cranial nerves evolve from the brain or brain stem and transmit motor or sensory messages. Deep tendon reflexes are part of the sensory pathway of the spinal cord which relay an impulse to the motor nerve and then to the muscles.
The nurse is doing a brainstem assessment on an unconscious client. Which of the following will the nurse examine during this part of the acute assessment? Select all that apply.
Corneal reflex, Gag reflex and Oculocephalic reflex (doll's eye maneuver)
The nurse is caring for a client in the hospital and identifies the client to be experiencing acute confusion after cardiac surgery. The nurse recognizes this as what?
Delirium Explanation: Delirium in an acute onset of confusion related to an underlying cause such as medication, disease or traumatic event. Dementia occurs over a time, amnesia is a loss of memory and hypoxia may be a cause of delirium.
A client sustains an injury to the brain stem. What is the most important assessment parameter that the nurse should perform for this client?
Depth of respirations Explanation: The brain stem controls many functions. The medulla oblongata contains the nuclei for the cranial nerves and has centers that control and regulate respiratory function, heart rate and force, and blood pressure. Movement and sensation of the extremities is controlled by various functions of the nervous system. Level of consciousness occurs when the brain does not receive enough oxygen.
A client cannot differentiate between sharp and dull pain sensations when a nurse tests with a safety pin. What is an appropriate action by the nurse?
Determine the ability to differentiate hot and cold temperatures Explanation: If a client cannot correctly differentiate between sharp and dull pain sensations, the nurse should test for temperature sensation. Temperature and pain sensations travel in the lateral spinothalamic tract, thus temperature is only tested if pain sensation is altered. If a client cannot feel pain, feeling a lighter touch is unlikely. Striking a tuning fork and placing it on the top of one foot tests vibratory sensation, not pain or touch. The nurse should not try another object and test on the upper dermatomes, as this would not likely change the results.
Which of the following would the nurse most likely expect to find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident?
Difficulty speaking Explanation: The frontal lobe contains Broca's area, which is responsible for speech. Injury to this area may lead to difficulty speaking. Difficulty with sounds would be associated with the temporal lobe. Loss of tactile sensation would be associated with the parietal lobe. Blurred vision would be associated with the occipital lobe.
A nurse cares for a client diagnosed with cranial nerve III disorder. What should the nurse expect to find in the client?
Drooping of eyelids Explanation: The client with disorder of cranial nerve III will have drooping of the eyelids. Inability to close eyes occurs due to damage of cranial nerve VII. Loss of visual field and swelling of the optic nerve occur due to damage of cranial nerve II.
Upon reviewing the client's medical record, the nurse finds the client has left ptosis. The nurse would assess the client for what?
Drooping of the left eye Explanation: Ptosis is drooping of the eye lid. Swelling of the optic nerve is papilledema. A loss visual fields may be associated with retinal detachment or damage.
When testing the biceps reflex, what type of response should the nurse expect if normal?
Elbow flexes and muscle contracts Explanation: To elicit the biceps reflex, the nurse should ask the client to partially bend the arm at elbow with palm up. The nurse places the thumb over the biceps and strikes the thumb with the reflex hammer. The normal finding with this reflex is the elbow flexes and contraction of the biceps muscle occurs. When assessing the brachioradialis reflex, the normal finding is flexion and supination of the forearm. The other two are not findings elicited with upper extremity reflexes.
The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on possibly omitting from the exam?
Hop on one foot Explanation: Hoping on one foot is often impossible for the older adult because of decreased flexibility and strength and may place the client at risk. The nurse needs to ensure the client's safety by standing close by, especially with tandem walking and Romberg testing, because some older clients may have difficulty with maintaining balance. However, these tests would not be omitted. Older clients may have a slow uncertain gait. This test, however, would not be omitted.
Which part of the brain controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions and maintains overall autonomic control?
Hypothalamus Explanation: The hypothalamus controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions. It maintains overall autonomic control. The medulla, part of the brain stem, controls the cardiac, respiratory, vomiting, and vasomotor centers, dealing with autonomic (involuntary) functions of breathing, blood pressure, and heart rate. The brain stem also contains the pons and midbrain. The cerebral cortex is the covering of the cerebrum. Its role is in memory, attention, and consciousness.
A nurse assesses a client for pupillary response of the eyes finds unilateral dilated pupils that are unresponsive to light or accommodation. The nurse recognizes that which cranial nerve is responsible for the damage of pupillary response?
III Explanation: Cranial nerve III is responsible for the damage of pupillary response. Cranial nerve I disorders cause damage of sense of smell. Cranial nerve V is responsible for the function of masseter muscle contraction. Cranial nerve II disorders damage vision due to retinal detachment or due to a lesion in the nerve.
A nurse assesses a client for pupillary response of the eyes and finds a unilateral dilated pupil that is unresponsive to light or accommodation. The nurse recognizes that which cranial nerve is responsible for the damage of pupillary response?
III Explanation: Cranial nerve III is responsible for the damage to pupillary response. Cranial nerve I disorders cause damage to sense of smell. Cranial nerve V is responsible for the function of masseter muscle contraction. Cranial nerve II disorders damage vision due to retinal detachment or due to a lesion in the nerve.
What should the nurse assess to test the function of the temporal lobe?
Impulses from the ear Explanation: The function of the temporal lobe is assessed by testing for impulses from the ear. To assess the function of the parietal lobe, the nurse should test for tactile sensation. Assessment of the frontal lobe is done by testing the client's communication. To assess the function of the occipital lobe, the nurse should test the ability to read.
A client reports that she is experiencing a tremour when she reaches for things. This worsens as she nears the "target." When the examiner asks the client to hold out her hands, no tremour is apparent. What type does this most likely represent?
Intention Explanation: Because it worsens as the target is approached, this represents an "intention" tremour. In this client, one may suspect cerebellar pathway disease, possibly from multiple sclerosis (one could also look for an intranuclear opthalmoplegia). A postural tremour occurs when a certain position is maintained; resting tremours occur can occur with diseases such as Parkinson's. These do not occur during sleep.
The nurse is caring for an adult client who suffers from a spinal cord hemisection due to a tumor. The client is unable to feel pain or temperature changes below the level of the tumor. What other symptoms should the nurse teach the family to expect the client to experience?
Loss of position sense, vibration, and motor function on same side of the body Explanation: Following a spinal cord hemisection, pain and temperature sensation, are lost below the level of the injury or lesion on the opposite side of the body. Position sense, vibration, and motor function are affected on the same side of the body.
What task should a nurse ask a client to perform to assess the function of cranial nerve XII?
Move the tongue from side to side Explanation: Asking the client to move the tongue from side to side assesses function of the hypoglossal nerve, cranial nerve XII. The function of cranial nerve XI can be assessed by asking the client to shrug the shoulders against resistance. The nurse asks the client to swallow water to assess the function of cranial nerves IX and X. Asking the client to walk in heel-to-toe fashion helps in assessment of balance.
The nurse suspects that a client is experiencing meningitis. Which assessment finding caused the nurse to make this clinical determination?
Pain and hip flexion when the neck is flexed Explanation: Pain and flexion of the hips and knees is a positive Brudzinski sign that suggests meningeal inflammation. If the hips and knees remain relaxed and the neck is able to be flexed to the chest, the client is not demonstrating signs of meningeal irritation. Pain behind the knees when fully extended is a normal finding in some people.
When testing sensory function of the trigeminal nerve (CN V), which of the following sensations would the nurse assess?
Pain and light touch Explanation: The sensory aspects of CN V are assessed for by testing pain sensation (confirmed by temperature sensation) and light touch.
A nurse performs a neurological examination on a client who sustained an injury to the spinal cord. What finding should the nurse expect when stroking the bottom of the client's feet?
Plantar flexion Explanation: An injury to the spinal cord or the brain causes abnormal posturing in the client. This includes plantar flexion of the feet when stroked. The Babinski reflex in newborns is when the bottom of the foot is stroked, the toes fan out. In the normal adult, the response to stroking the bottom of the foot is flexion of the toes. Dorsiflexion is part of the range of motion for the foot.
The nurse is assessing a client exhibiting dystonic movements. The nurse should review the client's medications from home to check whether he is taking which medications that may cause the dystonia?
Psychiatric medications Explanation: Dystonia is commonly due to the use of psychiatric medications, resulting in slow, involuntary movement of the trunk and larger muscles. These movements may also be accompanied by twisted postures.
What functions are attributed to sensory impulses? (Select all that apply.)
Regulation of internal autonomic functions, Body position in space and Conscious sensation Explanation: Sensory impulses not only participate in reflex activity, as previously described, but also give rise to conscious sensation, calibrate body position in space, and help regulate internal autonomic functions like blood pressure, heart rate, and respiration.
A nurse cares for an elderly client with right side hemiplegia and expressive aphasia. Which deficit should the nurse expect to find in the client?
Slow speech with appropriate meaning Explanation: The client diagnosed with right side hemiplegia and expressive aphasia can verbally state wishes. Expressive aphasia is also called Broca's aphasia in which the speech is slowed with difficult articulation but fairly clear meaning. Clients with Wernicke's aphasia have rapid speech with no meaning. Inability to recognize familiar objects is called agnosia. Trouble remembering familiar faces is termed prosophenosia. Both of these conditions can occur with damage to the temporal and occipital lobes of the brain.
The nurse documents "Romberg test positive" on a client's medical record. What did the nurse most likely assess in this client?
Swaying Explanation: A positive Romberg test is when the client sways and moves the feet apart to prevent falling. The Romberg test is not used to assess gait, hand grasps, or the brachial reflex.
A nurse is working with a client who is victim of a shooting. The client has an increased pulse rate and pupil dilation and is clearly in stress. The nurse recognizes the "fight-or-flight" response in this client and understands that this represents an activation of which of the following?
Sympathetic nervous system Explanation: The sympathetic nervous system ("fight-or-flight" system) is activated during stress and elicits responses such as decreased gastric secretions, bronchiole dilatation, increased pulse rate, and pupil dilatation. The parasympathetic nervous system functions to restore and maintain normal body functions, for example, by decreasing heart rate. The somatic nervous system mediates conscious, or voluntary, activities, whereas the autonomic nervous system (comprising the sympathetic and parasympathetic systems) mediates unconscious, or involuntary, activities. The central nervous system (CNS) encompasses the brain and spinal cord, which are covered by meninges, three layers of connective tissue that protect and nourish the CNS.
Which of the following assessments is most likely to provide insight into the function of the client's CN VIII?
Test the client's hearing for lateralization and bone and air conduction. Explanation: CN VIII is the acoustic nerve; function is thus tested by assessing the client's hearing. Shoulder shrugging tests CN XI; frowning and closing the eyes depend on CN VII. CN I is tested by assessing the client's ability to identify smells.
The nurse is performing the Romberg test as part of a client's focused neurological assessment. What finding would constitute a positive Romberg test?
The client moves her feet apart to prevent herself from falling. Explanation: The Romberg test assesses balance; swaying or repositioning during the test constitutes positive findings. The Romberg test does not address pain during neck flexion or teeth clenching. It does not require the client to touch the nose with a finger.
The nurse is planning to assess a client for graphesthesia. How will the nurse perform this phase of assessment?
The client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object. Explanation: Graphesthesia is the ability to identify what is being drawn on the client's body when the client's eyes are closed. Two-point discrimination is tested by having the client identify the number of points felts when touched with the ends of two applicators at the same time. Extinction is tested by simultaneously touching the client in the same area on both sides of the body at the same points and having the client identify the area touched. Point localization is tested by briefly touching the client and then asking the client to identify the points touched.
The nurse is tapping the spine for the level of vertebral pain. The nurse is testing the dermatomes.
True
Which action by a nurse demonstrates the correct technique to use the reflex hammer?
Use rapid wrist movement and strike the tendon Explanation: When using a reflex hammer, the nurse should use rapid wrist movement and strike the tendon briskly. Tapping gently will not cause the tendon to shorten and the reflex will not occur. The tendon should be palpated before striking the hammer to know the area. The nurse should encourage the client to relax the muscles because tenseness can inhibit a normal response.
A client presents to the health care clinic with reports of difficulty swallowing. Which cranial nerves will provide the nurse with information related to the problem? Select all that apply.
Vagus, Glossopharyngeal and Hypoglossa Explanation: Difficulty swallowing can be a finding with CVA, Parkinson's disease, myasthenia gravis, Gullian Barre, or cranial nerve dysfunction. The cranial nerves that the nurse should be aware of are IX (glossopharyngeal), X (vagus), and XII (hypoglossal). Cranial nerve VI (abducens) controls lateral eye movement. Cranial nerve XI (spinal accessory) innervates the neck and shoulder muscles.
A woman experienced syncope after hearing that her son was severely injured. She became pale and collapsed to the ground without injuring herself. On waking, she states that she felt very warm. She denies any other symptoms. There are no findings on examination. What caused her loss of consciousness?
Vasovagal syncope Explanation: This is a classic description of vasodepressor or vasovagal syncope with the feeling of warmth while bystanders note paleness. The lack of injury is also helpful, because she has maintained her protective reflexes. Injuring oneself can indicate a cardiac origin for syncope. Micturition syncope occurs with urination; no postural changes are mentioned, making postural hypotension unlikely.
When conducting a Romberg test, why does the nurse ask the client to stand feet together with eyes open and then closed?
Vision can compensate for loss of position sense. Explanation: In clients with ataxia from loss of position sense, vision compensates for the sensory loss. A client who stands well with eyes open but loses balance with eyes closed is exhibiting a positive Romberg sign. Client safety, vestibular defects, or the effects of repetition do provide the rationale for conducting the Romberg test in the stated manner.
The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the
glossopharyngeal. Explanation: The glossopharyngeal nerve contains sensory fibers for taste on posterior third of tongue and sensory fibers of the pharynx that result in the gag reflex when stimulated.
The portion of the brain that rims the surfaces of the cerebral hemispheres forming the cerebral cortex is the
gray matter. Explanation: The lobes are composed of a substance known as gray matter, which mediates higher-level functions such as memory, perception, communication, and initiation of voluntary movements. Consisting of aggregations of neuronal cell bodies, gray matter rims the surfaces of the cerebral hemispheres, forming the cerebral cortex.
The nurse is doing a neurologic screening examination. The nurse should include some aspect of which areas? Select all that apply.
mental status, cranial nerves, motor syste, sensory system and reflexes Explanation: A complete neurologic examination consists of evaluating the following five areas: mental status, cranial nerves, motor and cerebellar systems, sensory system, and reflexes.
A client reports resting and skipping exercise during a holiday from work. Which part of the nervous system is controlling this client's behavior?
parasympathetic Explanation: The parasympathetic nervous system conserves energy and resources during times of rest and relaxation. The central nervous system consists of the brain and spinal cord. The sympathetic nervous system mobilizes organs and their functions during times of stress and arousal. The cranial nerves emerge from within the cranial vault through skull foramina and canals to structures in the head and neck.
The symptom that would alert the nurse to a problem with cranial nerve III would be
ptosis Explanation: Ptosis is seen with damage to cranial nerve III.
The nurse is caring for a client during the immediate postoperative period after abdominal surgery. While performing a "neuro check" the nurse should assess the client's
sensation in the extremities. Explanation: A neuro check includes the following assessment points: level of consciousness, pupillary checks, movement and strength of extremities, sensation in extremities, and vital signs.
