Case Study: Neurological Assessment

In documenting the client's difficulty speaking, the nurse recalls that the client had difficulty forming some words and phrases. Before describing this finding on the assessment form, what additional data should the nurse consider? A. How many words per minute the client is able to speak. B. The client's ability to comprehend what is being asked. C. If any mouth drooping is observed when the client spoke. D. Whether the client is able to read the nurse's lips accurately.

B. The client's ability to comprehend what is being asked. Rationale: Aphasia should be assessed to determine if the client has lost the ability to comprehend information (receptive aphasia) or the ability to express herself (expressive aphasia). Most commonly, the client experiences both, referred to as global aphasia.

The nurse observes contraction of the biceps muscle and flexion of the forearm in response to the attempt to elicit the biceps reflex. What action should the nurse take in response to this finding? A. Record the finding as a 4+ deep tendon biceps reflex. B. Document that clonus was elicited by the reflex testing. C. Explain to the client that the reflex response was normal. D. Repeat the test at the same location to confirm the finding.

C. Explain to the client that the reflex response was normal. Rationale: The client's response is normal and should be documented as a 2+ response.

Next, the nurse asks the client to close his or her eyes. The nurse places the tuning fork in the palm of the client's left hand and asks to identify what it is. The client is unable to identify the tuning fork. What action should the nurse take in response to this finding? A. Document that the client is exhibiting left-sided astereognosis. B. Ask the client to open his or her eyes and identify the object being held. C. Place a comb in the client's left hand and ask him or her to identify the object. D. Hold the tuning fork on the back of the client's hand while trying to identify it.

C. Place a comb in the client's left hand and ask him or her to identify the object. Rationale: Stereognosis, the ability to recognize objects by touch, should be assessed by placing a familiar object in the client's hand. A tuning fork in not a familiar object to many people, so the nurse should replace the fork with a more familiar object, such as a comb.

Physiologic Adaptation: Before continuing the interview and assessment, the nurse enters the following initial data collected into a tablet: The client demonstrates difficulty speaking and previously reported feeling weak, passing out, and falling at home. Vital signs are currently T 97° F (36o C), Blood Pressure 140/88 mmHg, heart rate 92beats/min, and respirations 18 breaths/min. What terminology should be included in the nurse's documentation? A. Dysphagia. B. Tachycardia. C. Syncope. D. Paresis.

C. Syncope.

Nursing Process: Cranial Nerve Assessment - After completing the interview and mental status exam, the nurse tests the client's cranial nerves to determine if there is a deficit. The nurse observes the client moving through the six cardinal fields of gaze by following an object or fingers without the head moving. Which cranial nerves are tested when the nurse is evaluating the client's extra ocular movements? (Select all that apply. One, some, or all options may be correct.) A. Optic (CN II). B. Facial (CN VII). C. Trochlear (CN IV). D. Trigeminal (CN V). E. Abducens (CN VI). F. Oculomotor (CN III).

C. Trochlear (CN IV). E. Abducens (CN VI). F. Oculomotor (CN III). Rationale: CN II: Optic measures central and peripheral vision. CN VII: measures pain and temperature from ear area; deep sensations from the face; taste from anterior two thirds of the tongue; muscles of the face and scalp and lacrimal, submandibular, and sublingual salivary glands. CN IV: Trochlear measures eye movement via superior oblique muscles. CN V: Trigeminal measures sensory perception from skin of face and scalp and mucous membranes of mouth and nose; muscles of mastication (chewing). CN VI: Abducens measures eye movement via lateral rectus muscles. CN III: Measures motor to eye muscles, eye movement via medial and lateral rectus and inferior oblique and superior rectus muscles; lid elevation via the levator muscle; pupil constriction; ciliary muscles.

Nursing Process: Assessment of Motor Function - The nurse continues the neurological assessment by assessing motor function. Since the client is lying in bed, which action should the nurse take to observe small muscle movement and coordination? A. Use a reflex hammer to elicit arm movement. B. Assist the client to sit on the side of the bed. C. Stroke the lateral sides of the sole of each foot. D. Ask the client to touch the thumb to each finger.

D. Ask the client to touch the thumb to each finger. Rationale: While the client touches her thumb to each finger, the nurse observes for smooth, coordinated movement of the small muscles.

Based on the client's recent history of loss of consciousness and falling, what additional assessment takes priority? A. Pedal pulse volume. B. Deep tendon reflexes. C. Two-point discrimination. D. Blood pressure and heart rate and rhythm.

D. Blood pressure and heart rate and rhythm. Rationale: Hypotension and bradycardia can cause a loss of consciousness. Bradycardia may also be a sign of increased intracranial pressure.If the client has hypertension, it places the client at increased risk for a hemorrhagic stroke. If the client has cardiac irregularity, such as atrial fibrillation, the client should be evaluated and treated to prevent an embolic stroke.

The nurse observes that the client lacks coordination when touching the thumb to the fingers on the left side and decides to further assess upper extremity muscle strength. To assess upper extremity muscle strength, the nurse stands facing the client and holds out both hands toward the client. The nurse asks the client to grip two of the nurse's fingers with one hand and two fingers with the other hand. What instruction should the nurse provide next? A. Push my fingers back, using both hands at the same time. B. Squeeze my fingers with one hand, then with the other. C. Pull my fingers forward toward you, one hand at a time. D. Squeeze my fingers with both hands at the same time.

D. Squeeze my fingers with both hands at the same time. Rationale: When performing a hand grip test, the nurse asks the client to squeeze the nurse's fingers with both hands simultaneously, the nurse can compare muscle strength bilaterally.

After noting the size and shape of the client's pupils, the nurse tests the pupillary response to light. The nurse is preparing to test the client's pupillary response. (Place the steps in order from 1 to 6 from top to bottom.) 1. Have the client open both eyes. 2. Observe the eye being tested for constriction. 3. Bring a penlight in from the side of the client's head. 4. Have the client close both eyes and dim the lights in the room. 5. Shine the light in the eye being tested as soon as the client opens his or her eyes. 6. Note whether the other pupil constricts while the light shines into the eye being tested.

4, 3, 1, 5, 2, 6 Rationale: Testing pupils is a common cranial nerve test performed by nurses. Pupil constriction is a function of cranial nerve III, the oculomotor nerve. To test for pupil constriction, ask the patient to close his or her eyes and dim the room lights. Bring a penlight in from the side of the patient's head, and shine the light in the eye being tested as soon as the patient opens his or her eyes. The pupil being tested should constrict (direct response). The other pupil should also constrict slightly (consensual response).

The nurse tests cranial nerve XI by asking the client to shrug his or her shoulders. What action should the nurse perform? A. Slowly elevate both of the client's arms. B. Apply resistance to the client's shoulders. C. Internally rotate each of the client's shoulders. D. Observe the movement of the client's clavicles.

B. Apply resistance to the client's shoulders. Rationale: The nurse should test the client's ability to shrug his or her shoulders against resistance with equal strength bilaterally.

Nursing Process: Assessment of Sensory Function - After validating the finding of left-sided upper extremity weakness, the nurse next assesses the client's sensory function. The nurse uses a tuning fork to evaluate what sensory function? A. Pain. B. Vibration. C. Passive motion. D. Two point discrimination.

B. Vibration. Rationale: The client's ability to sense vibration is assessed by placing a vibrating tuning fork on a bony surface.

Case Outcome: The client's neurological function continues to worsen throughout the day. Resuscitative measures are not taken, in accordance with the designated Power of Attorney and the Living Will. The family is at the bedside at the time of death. Although saddened, the family acknowledges that they did what their parent wanted them to do.

END.

To objectively assess the client's level of consciousness, the nurse uses the Glasgow Coma Scale (GCS). What data should the nurse obtain to complete the client's GCS rating? (Select all that apply. One, some, or all options may be correct.) A. Orientation. B. Verbal response. C. Babinski reflex. D. Motor response. E. Pupillary response. F. Eye opening response.

A, B, D, F

During the interview, the nurse observes the client's speech patterns. The client seems to have difficulty choosing and forming some words. What action should the nurse take? A. Affirm the client's difficulty and ask about when this first started. B. Fill in the conversation with the words the client is attempting to say. C. Offer to complete the interview at a later time after the client has rested. D. Allow the client to respond and ignore any difficulty to avoid embarrassment.

A. Affirm the client's difficulty and ask about when this first started. Rationale: This action demonstrates caring and also enables the nurse to obtain a more complete history related to the onset of the client's symptoms.

Communication and Documentation: The nurse begins the admission assessment with the collection of assessment data that is immediately entered into the electronic health record (EHR). When eliciting data about possible neurological problems, what information should the nurse obtain from the client? (Select all that apply. One, some, or all options may be correct.) A. Any difficulty speaking or swallowing. B. Ever hear voices that no one else hears. C. Headache frequency and location. D. Any numbness, tingling, or weakness of extremities. E. Did the head hit the floor with syncopal episode.

A. Any difficulty speaking or swallowing. C. Headache frequency and location. D. Any numbness, tingling, or weakness of extremities. E. Did the head hit the floor with syncopal episode.

Safe and Effective Care: Alteration in Level of Consciousness - Shortly after completing the admission assessment, the nurse returns to the client's room and notes a change in condition. The client has slurred speech. Further assessment reveals that the client is no longer able to move either the left arm or leg, and within a few minutes no longer responds to the nurse's questions. The nurse quickly assesses the client's level of consciousness by checking for a response to varying stimuli. What stimuli should the nurse use first to attempt to elicit a response from the client? A. Call the client's name. B. Lightly touch the client's arm. C. Pinch the client's trapezius muscle. D. Vigorously shake the client's shoulder.

A. Call the client's name. Rationale: The nurse should begin with the least amount of stimulus and progress to the greatest amount of stimulus, observing the amount of stimulus needed to evoke a response by the client.

The nurse learns that the client designated the oldest as power of attorney, who tells the nurse that their parent was very clear in end of life wishes and does not wish to have external feeding, ventilation, or resuscitation implemented under any circumstances. To confirm the verbal information regarding the client's end of life wishes, the client plans to review the client's living will. What additional information related to end of life wishes is most important for the nurse to assess? A. Organ donor status. B. Desired funeral home. C. Wishes of other children. D. If the client prepared a will.

A. Organ donor status. Rationale: It is essential for the nurse to assess the client's wishes regarding organ donation so that any necessary arrangements to preserve organs can be made prior to the client's death.

The client's left upper extremity seems to be weaker than the right upper extremity. What additional assessment should the nurse perform to validate the finding of unilateral upper extremity weakness? A. Perform a palmar drift test. B. Complete a Romberg test. C. Check for a placing reflex. D. Observe for decorticate posturing.

A. Perform a palmar drift test. Rationale: A palmar drift test is used to assess upper extremity weakness. The client is asked to hold up both arms with the palms up and the eyes closed for 10 to 20 seconds. The weak arm will "drift" downward. The test validates the initial findings of left upper extremity weakness.

The nurse assesses the client's vital signs and level of consciousness and then proceeds to interview the client. To determine what happened to the client prior to the loss of consciousness, the nurse should obtain what information from the client? (Select all that apply. One, some, or all options may be correct.) A. Ask the client to stick out their tongue. B. Ask the client if they ever feel lightheaded or dizzy. C. Ask the client if they have any problems with smell. D. Ask the client if the dizziness occurs when they change positions. E. Ask the client if they felt like the room was suddenly spinning before they fell.

B. Ask the client if they ever feel lightheaded or dizzy. D. Ask the client if the dizziness occurs when they change positions. E. Ask the client if they felt like the room was suddenly spinning before they fell.

To continue to the cranial nerve VII assessment, the nurse asks the client to first smile, then frown, and then show his or her teeth. While the client performs these tasks, what should the nurse do? A. Apply light pressure over the facial nerve. B. Observe for symmetric facial movement. C. Gently palpate for swelling over the cheeks. D. Note how quickly the client completes each task.

B. Observe for symmetric facial movement. Rationale:

The nurse determines that the client is able to comprehend information but has difficulty with expressing them at times. The nurse documents that the client is experiencing expressive aphasia. Mental Status Exam: While continuing the interview, the nurse assesses the client's mental status. As the interview continues, the client occasionally struggles to choose and form words, but seems comfortable and relaxed. The nurse provides a quiet, calm environment, allowing ample time to respond to the interview questions. The client asks the nurse what the room number is, stating the need to let family know. Which assessment by the nurse accurately reflects the client's statement? A. Disoriented to place. B. Oriented to situation. C. Loss of recent memory. D. Loss of immediate memory.

B. Oriented to situation. Rationale: The client's statement describing the need to notify family that the client is in the hospital indicates an orientation to situation. Lack of knowledge of room number does not reflect disorientation or memory loss.

To assess the client's recent memory more completely, what action should the nurse take? A. Encourage reminiscing about the birth of a child. B. Question how the client arrived at the hospital today. C. List four words and ask the client to repeat them back. D. Observe the client's cooperation in answering interview questions.

B. Question how the client arrived at the hospital today. Rationale: This action provides information related to the client's recent memory. The nurse should ask questions with verifiable answers to ensure the client does not make up responses.

The client is able to identify a comb when it is placed in the right hand, but is unable to identify the comb when it is placed in the left hand. Nursing Process: Assessment of Deep Tendon Reflexes - The nurse continues the neurological assessment by evaluating the client's deep tendon reflexes (DTRs). The nurse begins by testing the client's biceps reflex. With the client's forearm resting on the nurse's forearm and the nurse's thumb over the biceps tendon, what action should the nurse take next to test the client's biceps reflex? A. Ask the client to contract the biceps muscle. B. Strike the thumb with the reflex hammer. C. Extend and externally rotate the client's forearm. D. Instruct the client to repeatedly clench the fist.

B. Strike the thumb with the reflex hammer. Rationale: With the client's forearm slightly flexed and relaxed, the nurse should strike the thumb with the pointed end of the reflex hammer to elicit a response.

The client's memory is vague about the events after passing out, but states that a neighbor called an ambulance to bring the client to the hospital. Which interview data provides the nurse with information related to the client's judgment? A. Reminiscing about the birth of a child caused the client to cry gently. B. The client indicated the need to notify family about being in the hospital. C. Repeating back a list of four words made the client anxious and uncomfortable. D. The client was cooperative but vague in describing how the neighbor found her.

B. The client indicated the need to notify family about being in the hospital. Rationale: The client's recognition of the need to notify family of being in the hospital is an indication of good judgment.