Health Assessment Chapter 22 Prep-U Neurological Assessment

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 with hypertension

What should the nurse assess to test the function of the occipital lobe?

Ability to read

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.

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

A nurse cares for a client who suffered a cerebrovascular accident and demonstrates the inability to speak clearly. The nurse recognizes that injury has occurred to what portion of the brain?

Broca's area

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

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

What should the nurse assess to test the function of the frontal lobe?

Communication

The nurse walks into a client's room and finds that the client is disoriented to time and place but is awake and responsive. What term best describes this patient?

Confused

What would the nurse most likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident?

Difficulty speaking

The nurse has assessed pupil size in a newly admitted client on the neuro-trauma unit. The client's pupils are unequal in size, and the healthcare provider is notified. The nurse is instructed that the findings indicate physiological anisocoria based on the healthcare provider's knowledge of the client's history. What is the nurse's best action?

Document the findings and healthcare provider's response.

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

When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence?

Mental status, cranial nerves, motor/cerebellar, sensory, reflexes

A client has sustained nerve damage as a result of an automobile accident and has lost the ability to sense position, vibration, and fine touch. Which neural pathway should the nurse suspect to be damaged?

Posterior columns

A client's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding?

Right knee +2; Left knee +1

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.

A client is visiting the health care facility for follow-up care for a stroke. Today he has increased muscle tone, some involuntary movements, an abnormal gait, and a slowness of response in movements. He most likely has involvement of which of the following?

The basal ganglia

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.

The nurse is assessing the neurologic system of an adult client. To test the client's motor function of the facial nerve, the nurse should

ask the client to purse the lips.

A client is concerned about tripping when walking and feeling uncoordinated. Which part of the brain might be causing this client's symptoms?

cerebellum

A nurse is planning care for a client who has been diagnosed with restless leg syndrome. Which intervention is the most effective for temporary relief of the symptoms?

exercising the legs

A client says that an object placed in the hand is a pair of scissors when the object is a paper clip. Which aspect of the client's neurologic system should the nurse identify as being compromised?

sensory

When the nurse is assessing the motor function of cranial nerve VII as part of the neurological examination, what should the nurse instruct the client to do?

smile

The Glasgow Coma Scale measures the level of consciousness in clients who are at high risk for rapid deterioration of the nervous system. A score of 13 indicates

some impairment.

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.