PUCH60 NEUROLOGIC ASSESSMENT PART 1

The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve? A. CN I B. CN II C. CN III D. CN IV

A

To evaluate a client's cerebellar function, a nurse should ask: A. "Do you have any problems with balance?" B. "Do you have any difficulty speaking?" C. "Do you have any trouble swallowing food or fluids?" D. "Have you noticed any changes in your muscle strength?"

A

Which finding is considered a positive finding of the Romberg test? A. Loss of balance B. Hoarseness in the voice C. Deviation of the tongue D. Tearing of the eye

A

Which lobe of the brain is responsible for concentration and abstract thought? A. Frontal B. Parietal C. Temporal D. Occipital

A

Which of the following neurotransmitters are deficient in myasthenia gravis? A. Acetylcholine B. GABA C. Dopamine D. Serotonin

A

A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects in the body systems, what does the nurse anticipate the liver will do? A. Cease function and shunt blood to the heart and lungs. B. Convert glycogen to glucose for immediate use. C. Produce a toxic byproduct in relation to stress. D. Maintain a basal rate of functioning.

B

Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed? A. Ataxia B. Clonus C. Rigidity D. Flaccidity

B

A client has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important postprocedure nursing intervention should be performed to ensure the client's maximum comfort? A. Administer antihistamines according to the physician's prescription B. Keep the room brightly lit and play soothing music in the background C. Help the client take a brisk walk around the testing area D. Encourage the client to drink liberal amounts of fluids

D

A nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm? A. milligram B. electroencephalogram C. echoencephalography D. cerebral angiography

D

To assess a client's cranial nerve function, a nurse should assess: A. hand grip. B. orientation to person, time, and place. C. arm drifting. D. gag reflex.

D

There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected with decreased visual fields. A. Cranial nerve I B. Cranial nerve II C. Cranial nerve III D. Cranial nerve IV

B

A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain? A. III B. IV C. V D. VI

C

The nurse is preparing the client for a diagnostic test to evaluate blood flow within intracranial blood vessels. For which test is the nurse preparing the client? A. Computed tomography B. Magnetic resonance imaging C. Transcranial Doppler D. Cerebral angiography

C

The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of which cranial nerve? A. II B. VI C. VIII D. XI

C

A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult that is slowing transmission of the motor neurons, in what would the nurse anticipate a delayed reaction? A. Identification of information due to slowed passages of information to brain. B. Cognitive ability to understand relayed information. C. Processing information transferred from the environment. D. Response due to interrupted impulses from the central nervous system

D

A nurse is evaluating a client's cranial nerves during a routine examination. To assess the function of cranial nerve XII (hypoglossal), the nurse should assess the client's ability to: A. smell and identify a nonirritating, aromatic odor. B. read an eye chart from a distance of 20?. C. elevate the shoulders, both with and without resistance. D. stick out the tongue and move it rapidly from side to side and in and out.

D

A 53-year-old man presents to the emergency department with a chief complaint of inability to form words, and numbness and weakness of the right arm and leg. Where would you locate the site of injury? A. Left frontoparietal region B. Right frontoparietal region C. Left basal ganglia D. Left temporal region

A

A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for: A. hypoxia. B. fever. C. visual disturbance. D. gait alteration.

A

Cranial nerve IX is also known as which of the following? A. Glossopharyngeal B. Vagus C. Spinal accessory D. Hypoglossal

A

The nurse is assessing the pupils of a patient who has had a head injury. What does the nurse recognize as a parasympathetic effect? A. Dilated pupils B. Constricted pupils C. One pupil is dilated and the opposite pupil is normal D. Roth's spots

B

The nurse is assisting with a lumbar puncture and observes that when the physician obtains CSF, it is clear and colorless. What does this finding indicate? A. A subarachnoid hemorrhage B. An overwhelming infection C. A normal finding; the fluid will be sent for testing to determine other factors D. Local trauma from the insertion of the needle

C

The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly? A. Moving the head toward both sides B. Lightly tapping the lower portion of the neck to detect sensation C. Moving the head and chin toward the chest D. Gently pressing the bones on the neck

C

The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve? A. Cranial nerve I B. Cranial nerve V C. Cranial nerve XI D. Cranial nerve XII

D

When learning about the nervous system, students learn that which nervous system regulates the expenditure of energy? A. Parasympathetic B. Central C. Peripheral D. Sympathetic

D

Which neurons transmit impulses from the CNS? A. Sensory B. Neurilemma C. Dendrites D. Motor

D

A client presents to the emergency department status postseizure. The physician wants to know what the pressure is in the client's head. What test might be ordered on this client? A. lumbar puncture B. echoencephalography C. nerve conduction studies

A

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis? A. Risk for aspiration B. Risk for falls C. Risk for impaired skin integrity D. Decreased intracranial adaptive capacity

A

A nurse is performing a neurologic assessment on the client and notes a positive Romberg test. This test for balance is related to which of the following cranial nerves? A. VIII B. X C. III D. VII

A

A patient arrives to have an MRI done in the outpatient department. What information provided by the patient warrants further assessment to prevent complications related to the MRI? A. "I am trying to quit smoking and have a patch on." B. "I have been trying to get an appointment for so long." C. "I have not had anything to eat or drink since 3 hours ago." D. "My legs go numb sometimes when I sit too long."

A

A patient has difficulty interpreting his awareness of body position in space. Which lobe is most likely to be damaged? A. Frontal B. Parietal C. Temporal D. Occipital

B

During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to: A. use the pointed end of the reflex hammer when striking the Achilles tendon. B. support the joint where the tendon is being tested. C. tap the tendon slowly and softly. D. hold the reflex hammer tightly.

B

Lower motor neuron lesions cause A. increased muscle tone. B. flaccid muscles. C. no muscle atrophy. D. hyperactive and abnormal reflexes.

B

The nurse is caring for a patient who was involved in a motor vehicle accident and sustained a head injury. When assessing deep tendon reflexes (DTR), the nurse observes diminished or hypoactive reflexes. How will the nurse document this finding? A. 0 B. 1+ C. 2+ D. 3+

B

The nurse is performing a neurologic assessment on a client diagnosed with a stroke and cannot elicit a gag reflex. This deficit is related to which of the following cranial nerves? A. VIII B. X C. III D. VII

B

The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart? A. CN I B. CN II C. CN III D. CN IV

B

The sympathetic and parasympathetic nervous systems have a direct effect on the circulatory system. Stimulation of the parasympathetic nervous system (PNS) causes which of the following? A. Blood vessels in the heart muscle to dilate B. Heartbeat to decrease C. Blood pressure to increase D. Blood vessels in the skeletal muscles to dilate

B

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term? A. Ataxic B. Dystrophic C. Helicopod D. Steppage

C

A client suspected of having a distortion of cerebral arteries and veins is scheduled for a cerebral angiography. What would the nurse tell the client about the upcoming test? A. That sedatives, coffee, tea, and soft drinks that contain caffeine will be withheld for at least 8 hours before the test to avoid affecting the diagnostic findings. B. The client will have to stay in a dark quiet room. C. Contrast will be given and a rapid sequence of radiographs will be taken. D. The client will have to shampoo his or her hair.

C

The provider orders the Romberg test for a patient. The nurse tells the patient that the provider wants to evaluate his equilibrium by assessing which cranial nerve? A. III B. VII C. VIII D. X

C

Which is a sympathetic effect of the nervous system? A. Decreased blood pressure B. Increased peristalsis C. Dilated pupils D. Decreased respiratory rate

C

If a client has a lower motor neuron lesion, the nurse would expect the client to exhibit A. hyperactive reflexes. B. no muscle atrophy. C. muscle spasticity. D. decreased muscle tone.

D

If a client has a lower motor neuron lesion, the nurse would expect to observe which manifestation upon physical assessment? A. Hyperactive reflexes B. No muscle atrophy C. Muscle spasticity D. Decreased muscle tone

D

A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by: A. introducing ice water into the external auditory canal. B. touching the cornea with a wisp of cotton. C. turning the client's head suddenly while holding the eyelids open. D. shining a bright light into the pupil.

C

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure? A. Prone, with the head turned to the right B. Supine, with the knees raised toward the chest C. Lateral recumbent, with thighs flexed D. Lateral, with right leg flexed

C