Neurologic Assessment

The nurse anticipates the patient with a Glasgow Coma Scale (GCS) score of 3 to be in which condition?

Comatose

Which assessments are included in the Glasgow Coma Scale?

Eye opening Verbal response Motor response

Which conditions are characteristic of lower motor neuron lesions?

Fasciculation Muscular atrophy

How would an adult patient normally respond to the plantar reflex?

Flexing the toes

Patients with which condition are at an increased risk for hemorrhagic stroke?

Hemophilia

Injury to which cranial nerve may cause anosmia in the patient?

I (olfactory nerve)

The nurse notes the absence of corneal, abdominal, and cremasteric reflexes on the right side of the patient's body with spastic paralysis on the left side of the body. Which is the probable reason for this condition?

damage to the corticospinal tract

Which test helps screen the gross and fine motor coordination skills of a child?

denver II

Degeneration if which structure would the nurse suspect in the patient with resting tremors, abnormally slow movement, flat expression, reduced eye blinking and slouched posture?

dopamine-producing neurons

The nurse assesses the patient's deep tendon reflexes to be very brisk and hyperactive, with clonus. Which grade would the nurse enter in the patient's medical record?

4+

Which percentage of the population has a dominant left hemisphere, including those who are left-handed?

95%

Which muscle tone abnormality would the nurse anticipate in a patient with Guillain-Barre syndrome?

flaccidity

Which response to the brachioradialis reflex test is documented as normal?

flexion and supination of the forearm

Which lobe of the brain is associated with personality and intellectual functioning?

frontal

The nurse observes a palmar grasps reflex in an 8-month-old infant and anticipates which diagnosis?

frontal lobe lesion (disappears at 3 to 4 months)

Which signs point to a diagnosis of Alzheimer disease?

mood swings disorientation loss of initiative

Which statement describes the efferent fibers?

motor neurons carrying impulses to the muscles, organs, and glands

Which lobe of the brain is associated with language comprehension?

temporal

The patient with aphasia has lost which ability?

understand language

Which action by the student nurse assessing a patient's pain perception requires correction?

applying the tongue blade on the patient's body in a systemic order

Which type of tremor is common in a patient with cerebral palsy?

athetosis

Which statement describes decerebrate rigidity?

back is hyperextended and the palms are pronated

Which findings would the nurse observe in a patient with flaccid quadriplegia?

complete loss of muscle tone paralysis of all four extremities

The nurse asks the patient to close their eyes and then traces the number 5 on the patient's palm. The patient is unable to identify the number even after repeated attempts. This finding could indicate damage to which part of the patient's brain?

sensory cortex

The reflex arc consists of which structures?

sensory nerve motor nerve neuromuscular junction

Which test involves the placement of a paper clip in the palm of a patient who eyes are closed and asking him or her to recognize the object?

stereognosis

The nurse flashes light into the eyes of a 5-year-old child and observes ocular misalignment and a deviated gaze. Which term would the nurse use to document this finding?

strabismus

Which reflex, if present in a 6-month-old infant, would prompt the nurse to immediately refer the patient to the provider?

Moro (disappears by 4 months)

Which response by the infant to having the nose pinched indicates a normally functioning cranial nerve XII?

Opens the mouth and raises the tongue

The nerve fibers present in the posterior column of the spinal cord carry information about which sensation?

Position and vibration

The patient with difficulty swallowing and regurgitation of ingested fluids through the nose may have a lesion on which cranial nerve?

X

Which instruction would the nurse give the patient to perform the Romberg test?

"Stand with feet together and eyes open then closed."

Which reflex helps the nurse assess the functioning of cranial nerve VIII (vestibulocochlear nerve) in an infant?

Acoustic blink

With the eyes closed, the patient is unable to identify by touch a key that is placed in the hand. The nurse uses which term to document this finding?

Astereognosis

Patients with which conditions are at risk for peripheral neuropathy?

Diabetes mellitus Nutritional deficiency

The nurse observes an older adult patient experience tremors while reaching for a pen. No tremors are noted at rest. Which medication would the nurse anticipate administering to the patient?

Diazepam (Valium)

In which patient would the nurse expect to find a palmar grasp reflex and a positive Babinski reflex?

Infant

The presence of which pathologic reflexes prompt the nurse to suspect meningeal irritation?

Kernig Brudzinski

Which tract of the central nervous system carries the sensations of pain and temperature?

Lateral spinothalamic

During the neurologic assessment, the nurse asks the patient to stand straight with the eyes closed. The nurse then instructs the patient to stretch out both arms with the palms facing up and to hold that position. The nurse observes that the patient's left palm starts turning downward within 10 seconds, though the patient can hold the right hand steady. Which condition would the nurse suspect?

Pronator drift

Which tests would the nurse perform to assess cerebellar function in a patient?

Romberg Finger-to-nose

For which conditions would the nurse assess in the patient unable to recognize the smell of coffee?

Sinusitis Allergic rhinitis Fracture of the cribriform plate

In which location would the nurse test a patient's superficial reflex?

Sole of the foot

The patient reports a sudden and severe throbbing headache and right arm weakness. Upon assessment, the nurse notes facial drooping and stuttered speech. The MRI reveals the development of an atherosclerotic plaque in the middle cerebral artery. The nurse anticipates the diagnosis of which type of stroke?

Thrombotic

Which cranial nerve would the nurse assess by touching a cotton wisp to the patient's forehead, cheeks, and chin?

V

The nurse suspects damage to which cranial nerve in a patient who has an asymmetric smile and is unable to wrinkle the forehead?

VII (facial nerve)

Which type of basic reflex includes the pupillary response and accommodation?

Visceral

The patient with cerebellar damage will likely experience a change in which characteristic?

Voluntary movements

Damage to which nerve can cause drooping of the upper eyelids in the patient with myasthenia gravis?

oculomotor

Which test is used to assess for a sensory cortex lesion?

point location

Which condition in the 3-year-old child prompts the nurse to suspect pyramidal tract disease?

positive babinski reflex