the point ch 22

When the nurse is assessing a client's mental status as part of the neurological examination, which question would be most appropriate to ask? "Do you have a history of psychotic disorder?" "Can you tell me where you are right now?" "Can you tell me about your mood today?" "Do you feel like crying often?"

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

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." "Hop on one spot." "Walk heel to toe." "Walk on your toes then on your heels."

"Walk across the room and back.

Which of the following is usually the first sign of neurological deterioration? Altered mentation and decreasing level of consciousness No response to painful stimulation Posturing Dilating pupil

Altered mentation and decreasing level of consciousness

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? Dysphonia Aphasia Dysarthria Apraxia

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? Use a Snellen chart to test visual acuity. Perform the Weber test. Ask a client to identify scents. Test extraocular eye movements.

Ask a client to identify scents

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? Instruct the client to walk across the floor and note the swinging of the arms Have the client stretch out the arms and bring one finger at a time to the nose Tell the client to stand with arms at the sides and note the presence of swaying Ask the client to walk in a heel-to-toe fashion and watch for an unsteady gait

Ask the client to walk in a heel-to-toe fashion and watch for an unsteady gait

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? Light touch sensation Deep tendon reflexes Leg strength Balance and coordination

Balance and coordination

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

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 II CN I CN VII CN IX

CN l

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. Axon Cell body Gyrus Cortex Dendrite

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? Parkinsonian gait Spastic hemiparesis Steppage gait Cerebellar ataxia

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 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

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? Asbestosis Tic Dystonia Chorea

Dystonia

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)

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) Vagus (X) Hypoglossal (XII) Spinal accessory (XI)

Glossopharyngeal (IX)

A client presents to the health care clinic with reports of difficulty swallowing. Which cranial nerves will provide the nurse with information related to the problem? Select all that apply. Spinal accessory Hypoglossal Trochlear Glossopharyngeal Abducens Vagus

Hypoglossal, vagus, glossopharyngeal

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? Ask the client to close the eyes Instruct the client to smile Instruct the client to state the current date and place Instruct the client to flex and extend the right elbow

Instruct the client to flex and extend the right elbow

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 Instruct the client to smile Ask the client to close the eyes Instruct the client to state the current date and place

Instruct the client to flex and extend the right elbow

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? Ischemic stroke Myasthenia gravis Lyme disease Parkinson disease

Myasthenia gravis

A client complains of headaches each morning that resolve after getting out of bed. What would be most appropriate for the nurse to do? Assess the client's level of consciousness. Assess the client's deep tendon reflexes. Refer the client for immediate medical follow-up. Refer the client for physical therapy and occupational therapy

Refer the client for immediate medical follow-up.

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'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 Right knee +4; Left knee +3 Right knee +3; Left knee +2 Right knee +1; Left knee 0 SUBMIT ANSWER

Right knee +2; Left knee +1

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

Which of the following assessments is most likely to provide insight into the function of the client's CN VIII? Ask the client to raise his or her eyebrows, frown, and close both eyes tightly. Test the client's ability to identify a familiar smell with his or her eyes closed. Test the client's hearing for lateralization and bone and air conduction. Ask the client to shrug both shoulders upward against the examiner's hands.

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 experiences pain when clenching her teeth. The client is unable to consistently touch her finger to her nose while her eyes are close. The client moves her feet apart to prevent herself from falling. The client experiences pain during neck flexion and extension.

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? Have the client close the eyes. The nurse will then gently touch the client, and the client will identify where the touch occurred. The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred. 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. The client is asked to identify the number of points felt when the nurse touches the client with the ends of two applicators at the same time.

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

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. Have the client close the eyes. The nurse will then gently touch the client, and the client will identify where the touch occurred. The client is asked to identify the number of points felt when the nurse touches the client with the ends of two applicators at the same time. The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred.

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.

When assessing cranial nerves IX and X, what would the nurse consider as a normal finding? Uvula and soft palate rising bilaterally Stationary soft palate on phonation Deviation of uvula when client says "ah" Asymmetrical soft palate

Uvula and soft palate rising bilaterally

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 Ask the client to identify the number of points touched with two ends of an applicator Use a blunt instrument to write a number in the client's hand and ask them to identify it With eyes closed, move the client's finger up or down and ask the direction

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

Which assessment procedure should a nurse institute to test a client for stereognosis? With eyes closed, move the client's finger up or down and ask the direction Use a blunt instrument to write a number in the client's hand and ask them to identify it Ask the client to identify the number of points touched with two ends of an applicator With eyes closed, ask the client to identify a familiar object that is placed in their hand

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

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? An intention tremor A postural tremor A resting tremor Myoclonus

a resting tremor

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 tumor

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

ability to read

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? Dysphonia Dysarthria Aphasia Apraxia

aphasia

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. Cortex Axon Gyrus Dendrite Cell body

axon dendrite cell body

A nurse is preparing to assess a client's cerebellar function. Which of the following would the nurse expect to test? Sensation Mental status exam Balance Remote memory

balance

A client has sustained an injury to the cerebellum. Which area should be the nurse's primary focus for assessment? Vital signs Coordination Cardiac function Respiratory status

coordination

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 hallucinations. schizophrenia. delirium. depression.

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? taking antidepressant medication resting the legs taking pain medication exercising the legs

excersizing the legs

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

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? Glasgow coma scale Health history Level of consciousness Pupillary reaction

health history

The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on possibly omitting from the exam? Gait Tandem walking Romberg Hop on one foot

hoops 1 foot

A nurse is reviewing a client's health record while interviewing her. The nurse sees in the client'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? Normal Present but decreased Exaggerated; indicator of possible upper motor neuron lesion Increased or brisk, but not pathologic

increased or brisk, but not pathologic

When reviewing the neural pathways, a group of students is identifying sensations that travel via the spinothalamic tract. Which sensations are carried by this tract? Select all that apply. Light touch Temperature Vibration Position Pain

pain temperture light touch

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 Extrapyramidal tract Posterior columns Spinothalamic tract

pyramidal tract

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 deep tendon reflexes. recent memory. sensation in the extremities. ability to speak.

sensation in the extremities

What task should a nurse ask a client to perform to assess the function of cranial nerve XI? walk in heel-to-toe fashion move tongue side to side swallow water shrug shoulders against resistance

shrug shoulders against resistance

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? Cover one eye. Smell coffee beans. Smile. Clench the teeth.

smile

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. Cover one eye. Clench the teeth. Smell coffee beans.

smile

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

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 severe impairment. deep coma. no verbal response. some impairment.

some impairment

Sensations of temperature, pain, and crude and light touch are carried by way of the spinothalamic tract. extrapyramidal tract. posterior tract. corticospinal tract.

spinothalamic tract

The nurse documents "Romberg test positive" on a client's medical record. What did the nurse most likely assess in this client? Weak hand grasps Poor brachial reflex Unsteady gait Swaying

swaying

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? somatic nervous system sympathetic nervous system autonomic nervous system peripheral nervous system

sympathetic nervous system

The diencephalon of the brain consists of the thalamus and hypothalamus. pons and brainstem. medulla oblongata and cerebrum. cerebellum and midbrain.

thalamus and hypothalamus

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

true

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? IV V III II

v

The nurse plans to test which cranial nerve when testing an elderly client's hearing status? V VI VII VIII

viii