Chapter 25 assessing the neurological system

The nurse is assessing the neurologic system of an adult client. To test the client's use of memory to learn new information, the nurse should ask the client

"Can you repeat brown, chair, textbook, tomato?"

When the nurse is assessing a client's mental status as part of the neurological examination, which question would be most appropriate to ask?

"Can you tell me where you are right now?"

During the health history of the nervous system, a client report having a history of generalized seizures. Which of the following should the nurse ask the client to determine characteristic symptoms of the seizures?

"What happens after the seizure?"

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 -Maintaining a healthy weight

Upon assessment, the nurse suspects the client is having a stroke. What symptoms might the nurse have found? Select all that apply.

-Severe headache -Slurred speech -Left arm weakness

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 in case they occur and she needs to call 911. 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 or coordination -Sudden severe headache with no cause

How many pairs of cranial nerves exit from the brain?

12

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

68-year-old african american male with hypertension

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

Ability to read

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

Absence

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

Ask the client to identify scents

The nurse is assessing the neurologic system of an adult client. To test the client's motor function of the facial nerve, the nurse should

Ask the client to purse the lips

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

Balance

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

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

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

Cerebellar ataxia

The husband of a 65-year-old female tells the nurse, "My wife is having trouble navigating the steps in our home and needs 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 husband of a 65-year-old female tells the nurse, "My wife is having trouble navigating the steps in our home and she needs 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

While assessing the neurologic system of a confused older adult, the nurse observes that the client is unable to recall past events. The nurse suspects that the client may be exhibiting signs of

Cerebral cortex disorder

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

Client stands erect with minimal swaying

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 would be the primary area for assessment?

Coordination

The cerebrum is divided into right and left hemispheres, which are joined together by the

Corpus callosum

When assessing deep tendon reflexes in an elderly client what finding would the nurse anticipate?

Decreased reaction time

During an admission assessment, the nurse notes that the client has diabetes with peripheral neuropathy. What finding would the nurse expect to find?

Decreased sensation in the feet

The nurse performing an admission assessment on an older adult. What would be an expected finding?

Decreased vision

A client visits the clinic and tells the nurse that he has not been feeling very well. The nurse observes that the client's speech is slow, the client has a disheveled appearance, and he maintains poor eye contact with the nurse. The nurse should further assess the client forq

Depression

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

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 nurse is planning care for a client who has been diagnosed with restless leg syndrome. Which intervention is the most effective for temporary relief of the symptoms?

Exercising the legs

During assessment, the nurse notes the client has limited movement of his lower extremities and sways when standing with feet together. The nurse identifies that the client is at risk for what?

Falls

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

False

The nurse is assessing the neurological status of an unconscious client. The nurse should use which assessment scale?

Glasglow

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

Glossopharyngeal

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

Glossopharyngeal (IX)

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 who presents to the health care clinic with suspected Bell's palsy. What finding should the nurse anticipate on examination?

Inability to wrinkle the forehead

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 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?

Interior tremor

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

L2 to L4

A client presents to the health care clinic with a 3-day history of fever, chills, neck pain and stiffness, and headache. The nurse observes an elevated temperature of 102.5°F and pain with rotation of the head side to the side and decreased ability to flex the head forward. The nurse recognizes these findings as most likely the onset of what infectious process?

Meningitis

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

A client reports resting and skipping exercise during a holiday from work. Which part of the nervous system is controlling this client's behavior?

Parasympathetic

A client's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding?

Right knee +2; Left knee +1

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

Shrug shoulders against resistance

The hypothalamus is responsible for regulating

Sleep cycles

The nurse is planning a presentation to a group of adults on the topic of strokes. Which of the following should the nurse plan to include in the teaching plan?

Smoking and high cholesterol levels are risk factors for STROKE.

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

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

Spinal cord

The nurse is preparing to perform the Romberg test on an adult male client. The nurse should instruct the client to

Stand erect with arms at the sides and feet together

A nurse is working with a client who is victim of a gun 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 clients hearing for lateralization and bone and air conduction

A client is visiting the health care facility for follow-up care for a stroke. Today he has increased muscle tone, some involuntary movements, an abnormal gait, and a slowness of response in movements. He most likely has involvement of which of the following?

The basal ganglia

The nurse is planning to test position sensation in an adult female client. To perform this procedure, the nurse should ask the client to close her eyes while the nurse moves the client's

Toes up or down

The nurse is admitting a client new to the clinic who states, "My face feels funny." When the nurse assesses the client she finds isolated facial sensory loss to pain and no neurologic deficits in his extremities. What diagnosis would the nurse expect for this client?

Trigeminal neuralgia

The nurse plans to test which cranial nerve when testing an elderly patient's hearing status?

VIII

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

Whisper test, rinne, and weber

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

Whisper, Rinner, 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 placed 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 hand and ask him or her to identify the object