Assessing Neurologic System

The nurse is preparing to assess a client's cranial nerves using a screening neurologic examination. Which of the following should the nurse include in this assessment? (Select all that apply.)

.Visual acuity Eye movements Hearing Facial strength

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

Cerebellar disease *In cerebellar disease, movements are clumsy, unsteady, and inappropriately varying in their speed, force, and direction. The finger may initially overshoot its mark, but finally reaches it fairly well, termed dysmetria. An intention tremor may appear toward the end of the movement.

The nurse is examining a child with severe cerebral palsy. On sudden movement of the child's foot dorsally, a sustained "beating" of the foot against the nurse's hand ensues. What does this represent?

Clonus *Clonus is a sustained rhythmical "beating" that correlates with CNS disease and hyperreflexia. A focal seizure could be virtually ruled out by stopping the stimulus and watching the phenomenon stop. Extinction is a term applied to sensory testing in which one side of a simultaneous, bilateral stimulus is not felt because of damage to the cortex. Reinforcement applies to enhancing reflex examination by distracting the client (e.g., pulling his hands against each other).

Which of the following would the nurse expect to assess if a client has a lesion of the sympathetic nervous system?

Constricted pupil unresponsive to light *A constricted pupil unresponsive to light or accommodation suggests a lesion of the sympathetic nervous system. Sympathetic nervous system stimulation would lead to bilateral dilated pupils. A unilaterally dilated pupil unresponsive to light or accommodation would suggest damage to cranial nerve III. Argyll Robertson pupils are associated with central nervous system syphilis, meningitis, brain tumor, or alcoholism.

A client sustains an injury to the brain stem. What is the most important assessment parameter that the nurse should perform for this client?

Depth of respirations *The brain stem controls many functions. The medulla oblongata contains the nuclei for the cranial nerves and has centers that control and regulate respiratory function, heart rate and force, and blood pressure. Movement and sensation of the extremities is controlled by various functions of the nervous system. Level of consciousness occurs when the brain does not receive enough oxygen.

When documenting assessment of the nervous system, a nurse should keep in mind what important principle?

Describe the response *When documenting assessment data on the nervous system, it is important for the nurse to describe the response rather than labeling the behavior.

A client cannot differentiate between sharp and dull pain sensations when a nurse tests with a safety pin. What is an appropriate action by the nurse?

Determine the ability to differentiate hot and cold temperatures *If a client cannot correctly differentiate between sharp and dull pain sensations, the nurse should test for temperature sensation. Temperature and pain sensations travel in the lateral spinothalamic tract, thus temperature is only tested if pain sensation is altered. If a client cannot feel pain, feeling a lighter touch is unlikely.

While performing a neurological assessment on a 56-year-old male, the nurse identifies the client may be experiencing a stroke. What symptoms would the nurse identified? Select all that apply.

Difficulty following instructions Slurred speech Impaired vision *Signs and symptoms of a stroke that would be found during a neurological assessment include difficulty following instructions, slurred speech and impaired vision. The client may or may not be oriented x 3 and the nurse would expect to find the client hypertensive.

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

Document the findings and healthcare provider's response. *Physiological anisocoria is not associated with any disease; therefore the nurse can document the findings. A second opinion is not needed; and the client does not need to be seen right away. Third nerve palsy presents with sudden ptosis, diplopia, and pain with a fixed and dilated pupil.

An ambulance brings an older adult client to the ED. The client's daughter found the client on the floor of the house; the client is almost unresponsive. It is unknown how long the client was on the floor. When performing an acute assessment on the client, which of the following may the health care team omit (leave out)?

Health history *Rapid assessment includes level of consciousness using the Glasgow coma scale, which scores verbal response, eye opening, and motor function. If the client can respond verbally, basic orientation is assessed. This also allows a basic speech/language assessment. Vital signs are part of an acute assessment. As soon as is practical, obtaining health history information helps identify potential sources of the problem, but it is not a part of the emergency assessment.

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 *Cranial nerve III is responsible for the damage to pupillary response. Cranial nerve I disorders cause damage to sense of smell. Cranial nerve V is responsible for the function of masseter muscle contraction. Cranial nerve II disorders damage vision due to retinal detachment or due to a lesion in the nerve.

A client reports that she is experiencing a tremour when she reaches for things. This worsens as she nears the "target." When the examiner asks the client to hold out her hands, no tremour is apparent. What type does this most likely represent?

Intention *Because it worsens as the target is approached, this represents an "intention" tremour. In this client, one may suspect cerebellar pathway disease, possibly from multiple sclerosis (one could also look for an intranuclear opthalmoplegia). A postural tremour occurs when a certain position is maintained; resting tremours occur can occur with diseases such as Parkinson's. These do not occur during sleep.

A nurse is performing a test of cranial nerve XII (hypoglossal) on an elderly client. When the client protrudes her tongue for the test, the tongue moves in and out uncontrollably. Which of the following should the nurse most suspect?

Intentional tremor *Older adults may experience intentional tremors (tremors that occur with intentional movements). This may be seen with extending the hands, head nodding for "yes or no," or extending one's tongue, which may protrude back and forth. Such tremors are not associated with disease, but they may cause embarrassment or emotional distress. Fasciculations and atrophy of the tongue may be seen with peripheral nerve disease. Injury of the central spinal cord is associated with extremity weakness. Sudden numbness and weakness of the muscles of the face, arms, and legs are associated with cerebrovascular accident (stroke).

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 *Asking the client to move the tongue from side to side assesses function of the hypoglossal nerve, cranial nerve XII. The function of cranial nerve XI can be assessed by asking the client to shrug the shoulders against resistance. The nurse asks the client to swallow water to assess the function of cranial nerves IX and X. Asking the client to walk in heel-to-toe fashion helps in assessment of balance.

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

Myasthenia gravis *Weakness made worse with repeated effort and improved with rest suggests myasthenia gravis.

The nurse suspects the client has increased intracranial pressure due to meningitis. What should the nurse assess?

Neck mobility *Neck mobility should be assessed if the nurse suspects meningitis. Extraoccular movements, confusion, and decreased level of consciousness is not part of the meningeal assessment.

Which cranial nerve controls pupillary constriction?

Oculomotor *The oculomotor nerve causes pupillary constriction, opening the eye (lid elevation), and most extraocular movements.

A client presents to the emergency department after being hit in the face with a baseball. The health care provider orders vision testing to be performed to assess the whether the cranial nerves are intact. The nurse should prepare to test which cranial nerves? Select all that apply.

Oculomotor Abducens Trochlear *The cranial nerves that control motor and sensation of the eyes are II (optic), III (oculomotor), IV (trochlear), and VI (abducens). Cranial nerve I is olfactory, which is associated with the client's sense of smell. The trigeminal is cranial nerve V, which tests the temporal and masseter muscles.

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

Psychiatric medications *Dystonia is commonly due to the use of psychiatric medications, resulting in slow, involuntary movement of the trunk and larger muscles. These movements may also be accompanied by twisted postures.

A client is clenching the jaw closed to avoid taking a prescribed oral medication. The nurse can use this observation to confirm the client is demonstrating motor function of which cranial nerve?

Trigeminal *The motor function of the trigeminal nerve includes the temporal and masseter muscles, both used with jaw clenching. The motor function of the facial nerve controls facial expression and closing the eyes and the mouth. The motor function of the glossopharyngeal nerve controls the pharynx. The motor function of the vagus nerve controls the palate, pharynx, and larynx.

The nurse is tapping the spine for the level of vertebral pain. The nurse is testing the dermatomes.

True

Which is true of examination of the olfactory nerve?

Unexpected responses may be seen in otherwise healthy elderly. *An abnormal olfactory nerve examination may be seen in otherwise healthy elderly, but may also be associated with other conditions such as Parkinson's disease. The examiner should try to determine if only one side is abnormal by occluding the contralateral nostril. The smell has only to be detected, not identified by name to indicate a normal examination. If nasal occlusion occurs for other reasons, such as allergic rhinitis or anatomical abnormalities, the nerve cannot be tested and may seem to be abnormal for unrelated reasons.

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

Use rapid wrist movement and strike the tendon *When using a reflex hammer, the nurse should use rapid wrist movement and strike the tendon briskly.

During an assessment of the cranial nerves, a client reports spontaneously losing balance. The nurse should focus additional assessment on which cranial nerve?

VIII *Sensory function of the acoustic nerve is both hearing (cochlear division) and balance (vestibular division). The sensory function of the olfactory nerve is the sense of smell. The sensory function of the trigeminal nerve covers three areas of the face: around the eyes, along the maxilla, and along the mandible. The hypoglossal nerve does not have a sensory function.

While assessing the pupils of a hospitalized adult client, the nurse observes that the client's pupils are dilated to 6 mm. The nurse suspects that the client is exhibiting signs of

oculomotor nerve paralysis. *Dilated pupil (6-7 mm) can indicate oculomotor nerve paralysis.

Where do the cell bodies of the lower motor neurons lie?

Spinal cord *Lower motor neurons have cell bodies in the spinal cord, termed anterior horn cells; their axons transmit impulses through the anterior roots and spinal nerves into peripheral nerves, terminating at the neuromuscular junction.

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?" *Clients with carotid artery disease may experience dizziness or lightheadedness, especially with ambulation because of the increased difficulty in circulating enough blood and oxygen to the brain. Trouble hearing and changes in vision may signal cranial nerve dysfunction. Weakness in the muscles of the extremities is an indication of a CVA or nerve injury.

A client reports the feeling of being unsteady when walking. What is an appropriate action by the nurse to assess for a problem with gait and balance?

Ask the client to walk in a heel-to-toe fashion and watch for an unsteady gait *To assess the presence of an unsteady gait, the nurse should ask the client to walk in a heel-to-toe fashion and watch for an unsteady gait. This is called tandem walking. Having the client stretch out the arms and bring one finger at a time to the nose tests for coordination. A normal gait should be steady, with the opposite arm swinging as the client walks; however, this observation does not inform the nurse regarding balance. Telling the client to stand with arms at the sides and noting the presence of swaying is the Romberg test, which test for balance but does not assess the client's gait.

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

Aura *The nurse should assess the client about an aura that forewarns the client of an impending seizure. Lightheadness, hallucinations and delusions are not associated with seizures.

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

Impulses from the ear *The function of the temporal lobe is assessed by testing for impulses from the ear. To assess the function of the parietal lobe, the nurse should test for tactile sensation. Assessment of the frontal lobe is done by testing the client's communication. To assess the function of the occipital lobe, the nurse should test the ability to read.

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

Decreased proprioception *In older people peripheral nerve function and impulse conduction decreases with resultant decreased proprioception and potential for a Parkinson-like gait.

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 *Delirium in an acute onset of confusion related to an underlying cause such as medication, disease or traumatic event. Dementia occurs over a time, amnesia is a loss of memory and hypoxia may be a cause of delirium.

When assessing a client's coordination by asking the client to touch the nose with the finger, what should a nurse keep in mind about a client's movements?

Dominant side will be more coordinated than nondominant side *A nurse should ask a client to touch the tip of the nose with the right index finger, then the left. This should be repeated three times. Movements should be smooth and performed without hesitation. The nurse should keep in mind that the client's dominant side will be more coordinated than the nondominant side. The elderly client may be slower but the movement should still be smooth and accurate. Movements should not become less accurate as the client repeats the maneuver.

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 all toes *An injury to the spinal cord or the brain causes abnormal posturing in the client. This includes dorsiflexion of the great toe and fanning of all toes when the sole of the foot is stroked—a positive Babinski reflex—which is normal in newborns but in adults is an indication of lesions of upper motor neurons or unconscious states resulting from drug and alcohol intoxication, brain injury, or subsequent to an epileptic seizure. In the normal adult, the response to stroking the bottom of the foot is flexion of the toes. Dorsiflexion and plantar flexion are not associated with this reflex.

Characteristics of the 12 cranial nerves include all of the following except that:

Each has motor and sensory functions. *Only some, but not all, cranial nerves possess both sensory and motor functions. They are paired and emerge from within the cranium, with each allowing for the performance of specialized and specific functions.

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

Increased or brisk, but not pathologic *Normal reflex scores range from 1+ (present but decreased) to 2+ (normal) to 3+ (increased or brisk, but not pathologic). Absent or markedly decreased (hyporeflexia) deep tendon reflexes (rated 0) occur when a component of the lower motor neurons or reflex arc is impaired and may be seen with spinal cord injuries. Markedly hyperactive (hyperreflexia) deep tendon reflexes (rated 4+) may be seen with lesions of the upper motor neurons and when the higher cortical levels are impaired.

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 *Pain and flexion of the hips and knees is a positive Brudzinski sign that suggests meningeal inflammation. If the hips and knees remain relaxed and the neck is able to be flexed to the chest, the client is not demonstrating signs of meningeal irritation. Pain behind the knees when fully extended is a normal finding in some people.

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

Pain and light touch *The sensory aspects of CN V are assessed for by testing pain sensation (confirmed by temperature sensation) and light touch.

A 21-year-old engineering student comes to your office complaining of leg and back pain and of tripping when he walks. He states this started 3 months ago with back and buttock pain but has since progressed to feeling weak in his left leg. He denies any bowel or bladder symptoms. He can think of no specific traumatic incidences, but he was a defensive lineman in high school and junior college. His past medical history is unremarkable. He denies tobacco use or alcohol or drug abuse. His parents are both healthy. On examination he is tender over the lumbar spine and he has a positive straight leg raise on the left. His Achilles tendon deep reflex is decreased on the left. While watching his gait the nurse notices that the client has to pick his left foot up high in order not to trip. What abnormality of gait does he most likely have?

Steppage gait *Steppage gait is associated with foot drop, usually secondary to a lower motor neuron disease. This is often seen with a herniated disc.

A client with a history of seizure disorder and taking several seizure medications reports that a friend noted "jumping eye movements." The client describes a sensation of movement at rest since his medications were adjusted upward following a breakthrough seizure several weeks ago. Examination shows that both eyes slowly move to the right then quickly jump to the left. Based on these signs, which of the following is true?

This is called nystagmus to the left. *Nystagmus is named for the fast component, in this case, toward the left. Nystagmus is common with several seizure medications and in this case is likely the result of a recent increase in medications rather than a more ominous cause. Sacchadic eye movements are similar to nystagmus but represent fixations on apparently moving objects, like watching roadside trees from a moving vehicle.

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 *A complete neurologic examination consists of evaluating the following five areas: mental status, cranial nerves, motor and cerebellar systems, sensory system, and reflexes.

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. *A neuro check includes the following assessment points: level of consciousness, pupillary checks, movement and strength of extremities, sensation in extremities, and vital signs.

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

spinothalamic tract. *Sensations of pain, temperature, and crude and light touch travel by way of the spinothalamic tract.

The nurse is assessing an older adult client when the client tells the nurse that she has experienced transient blind spots for the last few days. The nurse should refer the client to a physician for possible

stroke *Transient blind spots may be an early sign of a cerebrovascular accident (CVA).