Quiz 5: Ch 20 TNS

A client presents to the health care facility for a routine health checkup. The nurse learns that the client has a long history of cardiovascular disease including hypertension and carotid artery stenosis. When assessing this client for potential problems in the nervous system, which question by the nurse is appropriate?

"Are you having any dizziness or lightheadedness?"

A client presents to the health care facility for a routine health checkup. The nurse learns that the client has a long history of cardiovascular disease, including hypertension and carotid artery disease. When assessing this client for potential problems in the nervous system, which question by the nurse is appropriate?

"Are you having any dizziness or lightheadedness?"

The nurse is assessing CN V (trigeminal nerve) in a newly admitted client. What instruction should the nurse provide to the client during this phase of assessment?

"Clench your teeth together tightly"

During a routine follow up visit, an older adult client asks the nurse, "I've noticed that my sense of smell has decreased over the years and I'm concerned about the cause." What is the nurse's best response?

"Over time the sense of smell decreases in some people, and this is normal"

What instruction should a nurse give a client who is having trouble relaxing with the testing of the patellar deep tendon reflex?

"Place your hands together, lock fingers and squeeze"

What instruction should a nurse give a client when having trouble eliciting a response from testing the patellar deep tendon reflex?

"Place your hands together, lock your fingers and squeeze"

How many pairs of cranial nerves exit from the brain?

12

A nursing instructor is describing the peripheral nervous system to a group of students. The instructor would explain that there are how many pairs of spinal nerves?

31

When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as being at highest risk?

68 yr old male with hypertension

The nurse lightly strokes the sides of a client's abdomen, above and below the umbilicus. For which reflex is the nurse testing?

Abdominal

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

Ability to read

A 7-year-old child is performing poorly in school. Their teacher is frustrated because they are frequently seen "staring off into space" and not paying attention. If this is a seizure, it most likely represents which type?

Absence

The nurse is assessing a 39-year-old client who has a 20-year history of cigarette smoking. When reviewing the client's current medication administration record, what drug would the nurse identify as increasing the client's risk of stroke?

An oral contraceptive

On assessment of a client, the nurse finds that the client has difficulty in producing and understanding language. How should the nurse document this finding in the client's record?

Aphasia

A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. Which of the following would the nurse do?

Ask a client to identify scents

The nurse has completed a Glasgow Coma Scale assessment and assigns the client a score of three. Which is the best way for the nurse to assess pain in this client?

Assess for nonverbal signs

While conversing with a 42-year-old client, the nurse notes the client's tendency to repeatedly wink and shrug their shoulders at irregular intervals. The movements do not appear to correlate with the client's conversation. How should the nurse best follow up this observation?

Assess the client's medication regimen and history of recreational drug use

The nurse is assessing an newly admitted client with a seizure disorder. The nurse would asses the client for what?

Aura

A nurse is preparing to assess a client's cerebellar function. What aspect of neurological function should the nurse address?

Balance

A nurse is preparing to assess a client's cerebellar function. Which of the following would the nurse expect to test?

Balance

When assessing the client, the nurse notes bradykinesia. The nurse would know that this abnormality is caused by damage to what?

Basal ganglia system

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

The brain is a network of interconnecting neurons that control and integrate the body's activities. What components make up these neurons? Select all that apply.

Cell body, Axon, Dendrite

A nurse observes a client's gait and notes it to be wide based and staggering. The Romberg test results were positive. The nurse recognizes this as what type of abnormal gait?

Cerebellar ataxia

A nurse observes a client's gait and notes it to be wide-based and staggering. The Romberg test results were positive. The nurse recognizes this as what type of abnormal gait?

Cerebellar ataxia

As adults age, peripheral nerve function and impulse conduction decrease. What is the result of this decrease?

Cerebellar ataxia

During the Romberg test, a client is unable to stand with the feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would identify this as which of the following?

Cerebellar ataxia

During the Romberg test, a client is unable to stand with their feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would identify this as which of the following?

Cerebellar ataxia

The nurse working in the emergency department is assessing an intoxicated driver involved in a motor vehicle crash when the client insists on ambulating to the bathroom. The nurse escorts the client and calls for help while anticipating which abnormal gait in this client that places them at risk for falls?

Cerebellar ataxia

The nurse is assessing the client's coordination and finds that their movements are clumsy, unsteady, and inappropriately varying in their speed, force, and direction. The nurse notes that client has dysmetria. What would the nurse know this client has?

Cerebellar disease

The spouse of a 65-year-old female tells the nurse, "My spouse is having trouble navigating the steps in our home and they need 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

The nurse is performing the Romberg test. Which of the following indicate a normal finding?

Client stands erect with minimal swaying

When explaining how the nurse would test graphesthesia, which of the following would the nurse include?

Client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt ended object

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

Communication

A client has sustained an injury to the cerebellum. Which area should be the nurse's primary focus for assessment?

Coordination

A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment?

Coordination

While the nurse is performing as assessment of the eyes for a client, the nurse notes that one of the client's pupils is dilated and unresponsive to light. Which condition should the nurse suspect?

Cranial nerve III (oculomotor) damage

The nurse notes that a client in bed has the following posture. How should the nurse document this finding?

Decerebrate rigidity

The nurse is caring for a client in the hospital and identifies the client to be experiencing acute confusion after cardiac surgery. The nurse recognizes this as what?

Delirium

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 performs a neurological assessment and determines the Glasgow Coma Scale (GCS) score is 15. What is the nurse's best action?

Document the findings

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 health care provider is notified. The nurse is instructed that the findings indicate physiological anisocoria based on the health care provider's knowledge of the client's history. What is the nurse's best action?

Document the findings and health care providers response

A nurse performs a neurologic examination on a client who sustained an injury to the spinal cord. What finding should the nurse expect when stroking the bottom of the client's feet?

Dorsiflexion of the great toe and fanning of the toes

Upon reviewing the client's medical record, the nurse finds the client has left ptosis. The nurse would assess the client for what?

Drooping of the left eye

Nursing students are doing a class presentation on stroke. What is the term they would use for deficits in speech articulation?

Dysarthria

A 48-year-old grocery store manager comes to the clinic complaining of their head being "stuck" to one side. They say that today they were doing their normal routine when it suddenly felt like their head was being moved to their left and then it just stuck that way. They say it is somewhat painful because they cannot move it back to a normal position. They deny any recent neck trauma. Their past medical history consists of type 2 diabetes and gastroparesis (slow-moving peristalsis in the digestive tract, seen in diabetes). They are taking oral medication for each. They are married with three children. They deny tobacco, alcohol, or drug use. Their parent has diabetes and their birth parent passed away from breast cancer. Their children are healthy. Examination reveals a slightly overweight Hispanic adult client appearing their stated age.

Dystonia

When testing the biceps reflex, what type of response should the nurse expect if normal?

Elbow flexes and muscle contracts

After testing deep tendon reflexes, the nurse documents 2+. The nurse should evaluate further.

False

A 7-year-old child comes to the clinic with their parent, who states that the child is doing poorly in school because they have some kind of "ADD" (attention deficit disorder). The nurse asks the parent what makes them think the child has ADD. The parent says that both at home and at school their child just zones out for several seconds and licks their lips. They state it happens at least four to six times an hour. The parent says this has been happening for about 1 year. After several seconds of lip licking, the child seems normal again. The parent states their child has been generally healthy with just normal childhood colds and ear infections. The client's parents are both healthy; no other family members have had these symptoms. What type of seizure disorder is most likely?

Generalized absence seizure

The nurse is caring for a client with a history of seizure disorder. The nurse observes the client making severe jerky movements (extending and contracting extremities) and the client loses consciousness. The nurse will identify this as which type of seizure?

Generalized seizure

A client who was injured by a fall at a construction site has been admitted to the hospital. They have suffered nerve damage such that their gag reflex is no longer intact, requiring them to receive intravenous total parenteral nutrition. Which nerve should the nurse suspect to be involved in this client's injury?

Glossopharyngeal (IX)

The portion of the brain that rims the surfaces of the cerebral hemispheres forming the cerebral cortex is the

Gray matter

The nurse assessing a client understands that which of the following could be due to increased intracranial pressure? Select all that apply.

Headache that subsides after arising Blurred vision

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

Which part of the brain controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions and maintains overall autonomic control?

Hypothalamus

A nurse assesses a client for pupillary response of the eyes and finds a unilateral dilated pupil that is unresponsive to light or accommodation. The nurse recognizes that which cranial nerve is responsible for the damage of pupillary response?

III

A nurse assesses a client for pupillary response of the eyes finds unilateral dilated pupils that are unresponsive to light or accommodation. The nurse recognizes that which cranial nerve is responsible for the damage of pupillary response?

III

A nurse is reviewing a client's health record while interviewing them. The nurse sees in the client's record a score of 3+ on the biceps reflex test from their previous visit. The nurse understands that this finding indicates which of the following?

Increased or brisk, but not pathologic

The nurse assesses the motor system as part of the full neurological examination. In order to effectively assess this system, which of the following instructions should be given to the client?

Instruct the client to flex and extend the right elbow

A 37-year-old insurance agent comes to the office with a report of trembling hands. They say that for the past 3 months when they try to use their hands to fix their hair or cook, they shake badly. They say they don't feel particularly nervous when this occurs, but they worry that other people will think they have an anxiety or alcohol use disorder. They admit to having some recent fatigue, trouble with vision, and difficulty maintaining bladder control. Their past medical history is remarkable for hypothyroidism. One parent has lupus and the other parent is healthy. They have an older sibling with type 1 diabetes. They are married with three children. They deny tobacco, alcohol, or drug use. On examination, when the client tries to reach for a pencil to fill out the health form, they have obvious tremors in their dominant hand. What type of tremor is most likely?

Intention tremor

What is the level of the spinal cord associated with the knee (patellar) deep tendon reflex?

L2 to L4

A nurse is having difficulty eliciting a patellar reflex. Which of the following would be most appropriate for the nurse to have the client do?

Lock the fingers together and pull against each other

The nurse is doing a neurologic screening examination. The nurse should include some aspect of which areas? Select all that apply.

Mental status Cranial nerves Motor system Sensory system Reflexes

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

What task should a nurse ask a client to perform to assess the function of cranial nerve XII?

Move the tongue from side to side

The client presents at the clinic with a report of weakness that is made worse with repeated effort and improves with rest. The client's report is consistent with what health problem?

Myasthenia gravis

Which cranial nerve controls pupillary constriction?

Oculomotor

Which of the following would lead the nurse to suspect meningeal irritation?

Pain and flexion of the hips and knees with neck flexion

The nurse suspects that a client is experiencing meningitis. Which assessment finding caused the nurse to make this clinical determination?

Pain and hip flexion when the neck is flexed

When testing sensory function of the trigeminal nerve (CN V), which of the following sensations would the nurse assess?

Pain and light touch

The nurse is testing a client for Kernig sign. Which finding(s) should cause the nurse to suspect meningeal irritation? Select all that apply.

Pain when knee is extended, resistance to knee extension

Examination of a client's gait reveals that the client is stooped over when walking and that they slowly shuffle. As well, the client maintains a stiff posture when walking. The nurse should document what type of gait?

Parkinsonian gait

A client is in the emergency room with what could be a lumbar injury. Which deep tendon reflex would be most appropriate to test?

Patellar

A 20-year-old comatose high school student arrives at the emergency room. Their friends have accompanied them and report that they have been shooting up heroin tonight and think their friend may have had too much. The client is unconscious and cannot protect their airway so they are intubated. Their heart rate is 60 and they are breathing through the ventilator. They are not posturing and they do not respond to a sternal rub. On neurological examination with a penlight, what type of pupils is the examiner likely to see in this comatose client?

Pinpoint

The nurse is assessing a client exhibiting dystonic movements. The nurse should review the client's medications from home to check whether they are taking which medications that may cause the dystonia?

Psychiatric medication

The symptom that would alert the nurse to a problem with cranial nerve III would be

Ptosis

Lifestyle can play a big part in developing risk factors for stroke. Which of the following can greatly reduce a client's risk for stroke? Select all that apply.

Quitting smoking Regularly exercising Maintaing a healthy weight

The emergency department nurse's rapid assessment of a young adult client admitted unresponsive reveals fixed, constricted pupils bilaterally. The nurse should consider what possible cause for this assessment finding?

Recent opioid use

The nurse is caring for a client during the immediate postoperative period after abdominal surgery. While performing a "neuro check" the nurse should assess the client's

Sensation in the extremities

What task should a nurse ask a client to perform to assess the function of cranial nerve XI?

Shrug shoulders against resistance

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

A nurse is instructing a client who has recently experienced a transient ischemic attack (TIA) on warning signs of a stroke that the client should be aware of. Which of the following should the nurse mention? Select all that apply.

Sudden numbness or weakness of the face Sudden confusion, trouble speaking, or understanding speech Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance coordination Sudden severe headache with no known cause

A nurse is working with a client who is victim of a shooting. The client has an increased pulse rate and pupil dilation and is clearly in stress. The nurse recognizes the "fight-or-flight" response in this client and understands that this represents an activation of which of the following?

Sympathetic nervous system

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

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 their feet apart to prevent themself from falling

Which action by a nurse demonstrates the correct technique to use the reflex hammer?

Use rapid wrist movement and strike the tendon

When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding?

Uvula and soft palate rising bilaterally

When assessing cranial nerves IX and X, what would the nurse consider as a normal finding?

Uvula and soft palate rising bilaterally on phonation

The nurse plans to test which cranial nerve when testing an older adult client's hearing status?

VIII

Which tests are appropriate for a nurse to perform to test cranial nerve VIII?

Whisper, Rinne and Weber tests

Which assessment procedure should a nurse institute to test a client for stereognosis?

With eyes closed, ask the client to identify a familiar object that is places in their hand

Which of the following assessment techniques should the nurse use to determine a client's stereognosis?

With the clients' eyes closed, place a coin or key in their hand and ask them to identify the object

A nurse is performing a focused cranial assessment on a client. The nurse observes that the client is unable to shrug their shoulders. The nurse documents this as a dysfunction of which cranial nerve?

XI

While the nurse is assessing a client's coordination, the client exhibits uncoordinated, jerky movements and is unable to touch either finger to the nose. Which condition should the nurse suspect?

cerebellar disease

The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the

glossopharyngeal

Sensations of temperature, pain, and crude and light touch are carried by way of the

spinothalamic tract

The diencephalon of the brain consists of the

thalamus and hypothalamus