Test 5: Neuro Prep U

When the nurse is assessing a client who is comatose, which actions should be included in the assessment? Select all that apply.

- determining level of consciousness - assessing airway, circulation, and breathing - obtaining the medical history

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 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

When reviewing the neural pathways, a group of students identify which of the following as sensations that travel via the spinothalamic tract. Select all that apply.

Pain Temperature Light touch

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

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

Parkinsonian gait

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

A nurse is working with a client who suffered nerve damage during surgery for removal of a tumor. The client, who is an artist, lost fine motor control in his hands and can no longer manipulate a paintbrush. Which neural pathway should the nurse suspect to be damaged?

Pyramidal tract

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."

The nurse is providing teaching to a client with type 1 diabetes. When providing information about reducing the risk of diabetic neuropathy, the nurse should be sure to include which point?

"Effective blood glucose regulation can prevent this problem."

A nurse is assessing a client for abnormalities of gait due to a concern that the client is at increased risk for a fall. Which instruction should the nurse give the client first?

"Walk across the room and back."

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 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?"

When 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

A client who has had a stroke has no eye or verbal response but withdraws from painful stimuli. How would the nurse score these responses using the Glasgow Coma Scale?

6

While the client is sitting quietly, the thumb and index finger of the left hand are moving in a circular motion. The nurse identifies this finding as which of the following problems?

A resting tremor

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

Which of the following is usually the first sign of neurological deterioration?

Altered mentation and decreasing level of consciousness

The nurse is assessing a 39-year-old woman 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 woman's risk of stroke?

An oral contraceptive

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

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 his 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 has positioned a client supine and asked her to perform the heel-to-shin test. An inability to run each heel smoothly down each shin should prompt the nurse to perform further assessment in what domain?

Balance and coordination

A client is experiencing a new onset of ataxia. Where should the nurse identify on the diagram the part of the brain that is affected in this client?

the cerebellum

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

Jim, an HIV-positive client, reports back pain in addition to several other complaints. On percussion, there is slight tenderness over the T7 vertebrae. When the nurse flexes the client's thigh to 90 degrees and extends his lower legs, strong resistance occurs at about 45 degrees of extension. What are likely causes of this constellation of symptoms?

Infection

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 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

During the health history a client reports a decrease in his ability to smell. During the physical assessment, the nurse would make sure to assess which cranial nerve?

CN I

During the health history, a client reports a decrease in his ability to smell. During the physical assessment, the nurse would make sure to assess which cranial nerve?

CN I

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 Dendrite Axon

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

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 him at risk for falls?

Cerebellar ataxia

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

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

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

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

L2 to L4

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

true

The nurse is caring for an adult client who suffers from a spinal cord hemisection due to a tumor. The client is unable to feel pain or temperature changes below the level of the tumor. What other symptoms should the nurse teach the family to expect the client to experience?

Loss of position sense, vibration, and motor function on same side of the body

A 37-year-old comatose woman arrives at the emergency room. Paramedics say her husband found her unconscious at home. Her past medical history consists of type 1 diabetes for which she takes insulin. In the ambulance the paramedics obtained a glucose check and determined she was severely hypoglycemic. They began a dextrose saline infusion and intubated her to protect her airway. Despite their efforts she is posturing in the emergency room with her arms straight at her side and her jaw clenched. Her legs are also straight and her feet are plantar flexed. What type of posturing is she showing?

Decerebrate rigidity

What would the nurse most likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident?

Difficulty speaking

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 48-year-old grocery store manager comes to the clinic complaining of her head being "stuck" to one side. She says that today she was doing her normal routine when it suddenly felt like her head was being moved to her left and then it just stuck that way. She says it is somewhat painful because she cannot move it back to a normal position. She denies any recent neck trauma. Her past medical history consists of type 2 diabetes and gastroparesis (slow-moving peristalsis in the digestive tract, seen in diabetes). She is taking oral medication for each. She is married with three children. She denies tobacco, alcohol, or drug use. Her father has diabetes and her mother passed away from breast cancer. Her children are healthy. Examination reveals a slightly overweight Hispanic woman appearing her stated age. Her head is twisted grotesquely to her left; otherwise, her examination is normal. What form of involuntary movement does she have?

Dystonia

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

Elbow flexes and muscle contracts

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

The nurse is testing the biceps strength in a young man following spinal trauma from a motor vehicle accident. The client cannot lift his hand upward, but if the arm is abducted to 90 degrees, he can then move his forearm side to side. This would represent a muscle strength grading of which of the following?

II

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

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

Impulses from the ear

A 77-year-old retired school superintendent comes to the office with a report of unsteady hands. He says that for the past 6 months when his hands are resting in his lap they shake uncontrollably. He says that when he holds them out in front of his body or uses his hands, the shaking improves. He also complains of some difficulty getting up out of his chair and walking around. He denies any recent illnesses or injuries. His past medical history is significant for high blood pressure and coronary artery disease, requiring a stent in the past. He has been married for more than 50 years and has five children and 12 grandchildren. He denies any tobacco, alcohol, or drug use. His mother died of a stroke in her 70s and his father died of a heart attack in his 60s. He has a younger sister with arthritis. His children are all essentially healthy. Examination reveals a fine pill-rolling tremour of his left hand. His right shows less movement. His cranial nerve examination is normal. He has some difficulty rising from his chair, his gait is slow, and it takes him time to turn around to walk back towards the examiner. He has almost no "arm swing" with his gait. What type of tremour is most likely?

Resting

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

A client is admitted to the health care facility with new onset of right-sided paralysis, slurred speech, and lethargy. A nurse obtains in the history that the client has uncontrolled hypertension and smokes 2 packs of cigarettes a day. Which nursing diagnosis is priority for the client upon admission?

Risk for Aspiration

As people age, several neurological changes occur. Neurons, brain size, and neurotransmitters decrease. What are some of the results of aging on the neurological system? Select all that apply.

Slower thought processing Reduced response to stimuli Delayed reflexes

When the nurse is assessing the motor function of cranial nerve VII as part of the neurological examination, what should the nurse instruct the client to do?

Smile

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

Spinal cord

The nurse documents "Romberg test positive" on a client's medical record. What did the nurse most likely assess in this client?

Swaying

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 her feet apart to prevent herself from falling.

The nurse is planning to assess a client for graphesthesia. How will the nurse perform this phase of assessment?

The 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.

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.

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

True

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, what would the nurse consider as a normal finding?

Uvula and soft palate rising bilaterally

The nurse notes that a client does not blink the left eye when the cornea is lightly touched with a cotton wisp. On which cranial nerve should the nurse focus additional assessment?

V

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

VIII

Which area of the brain integrates the understanding of spoken and written words?

Wernicke's area

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, 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 placed in their hand

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

With the client's eyes closed, place a coin or key in hand and ask him or her to identify the object.

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

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 for

depression

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

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

glossopharyngeal

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

gray matter.

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

patellar

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.

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

spinothalamic tract.

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.

Which body functions are related to the hypothalamus? Select all that apply.

sweating on a hot day feeling worried about an exam experiencing a regular menstrual cycle

A nurse is preparing to offer a community education session on anxiety. Which part of the nervous system should the nurse include in the discussion?

sympathetic nervous system

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

tactile sensation

The diencephalon of the brain consists of the

thalamus and hypothalamus.