HESI EAQ - Neurologic and Sensory Systems

While assessing a client the nurse observes abnormal rigidity with pronation of the arms. Which condition should the nurse record in the assessment findings? Decortication Pronator drift Babinski's sign Decerebration

Decerebration Abnormal movement with rigidity on extension of the arms and legs, pronation of the arms, and plantar flexion is called decerebration. The condition found in the client related to decerebration should be recorded in the assessment findings. Decortication is abnormal movement where arms, wrists, and fingers are flexed with internal rotation and plantar flexion of the legs. Pronator drift is the drifting of the arm on pronating the palm. Babinski's sign is dorsiflexion of the great toe and fanning of the other toes when the sole of the foot is stroked.

A nurse is assessing a client with Parkinson disease. Which assessment finding indicates the presence of bradykinesia? Intention tremor Muscle flaccidity Paralysis of the limbs Lack of spontaneous movement

Lack of spontaneous movement Bradykinesia is a slowing down in the initiation and execution of movement. Tremors are more prominent at rest and are known as nonintention, not intention, tremors. Cogwheel rigidity, not flaccidity, occurs because the disorder causes sustained muscle contractions. The limbs are rigid and move with a jerky quality; the limbs are not paralyzed.

A client is admitted to the hospital after having a tonic-clonic seizure. The client has a two-year history of a seizure disorder, but the seizures have been well controlled by phenytoin for the last six months. The client says to the nurse, "I am so upset. I didn't think I was going to have more seizures." Which is the best response by the nurse? "Did you forget to take your medication?" "You are worried about having more seizures?" "You must be under a lot of stress right now." "Don't be too concerned because your medication needs to be increased."

"You are worried about having more seizures?" The response "You are worried about having more seizures?" addresses the client's feelings and encourages communication. The question "Did you forget to take your medication?" sounds accusatory; it ignores the client's feelings and discourages communication. Although the statement "You must be under a lot of stress right now" may be true, it does not encourage further communication concerning the seizure. The statement "Don't be too concerned because your medication needs to be increased" negates the client's feelings and discourages communication.

While making rounds, the nurse finds a client lying on the floor next to a wheelchair. The client states, "I was trying to get back to bed and slipped." What should be the nurse's initial action? Call the nurse manager to alert administration. Arrange for the client to be examined by the in-house healthcare provider. Complete an incident report to ensure documentation of the event. Provide information about the incident to the client's primary healthcare provider.

Arrange for the client to be examined by the in-house healthcare provider. The client must be assessed to determine the response to the fall, and treatment instituted if necessary. Eventually the nurse manager and nursing administration should be informed; however, at this time the client's status is the priority. Eventually an incident report should be completed; however, at this time the client's status is the priority. Eventually the healthcare provider should be informed; however, at this time the client's status is the priority.

An older client experiences a cerebral vascular accident (CVA) and has right-sided hemiplegia and expressive aphasia. The client's children ask the nurse which functions will be impaired. Which abilities does the nurse explain will be affected? Stating wishes verbally Recognizing familiar objects Comprehending written words Understanding verbal communication

Stating wishes verbally Impaired ability to state wishes verbally is a characteristic of expressive aphasia[1][2] from damage to Broca area in the dominant hemisphere of the brain. Not recognizing familiar objects is known as agnosia; it is not related to expressive aphasia. Not comprehending written words is known as alexia or dyslexia, a type of receptive aphasia. Not understanding verbal communication is related to receptive aphasia.