Assessment: Ch 25 - Assessing Neurologic System
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?" Explanation: 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.
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?" Explanation: Remote memory (past dates and historical accounts) may be impaired in cerebral cortex disorders.
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." Explanation: It is important to ask the client to walk across the room and walk back first because this will reveal deficits in the gait. This, in turn, will allow the nurse to focus the assessment. Asking the client to walk across the room and then back assists the nurse in observing posture, balance, swinging of the arms, and movements of the legs. Asking the client to walk heel to toe is called "tandem walking." It would be appropriate to instruct the client to do this to determine if there is ataxia that was not previously obvious. Asking the client to walk on the toes then on the heels assists the nurse in assessing for plantar flexion of the ankles as well as for balance. The nurse should instruct the client to do this if problems with balance are noted initially. Asking the client to hop in place provides information about the client's position sense and cerebellar function. If the nurse is not yet aware whether the client is at risk for falls, this assessment should be left until the quality of gait has been assessed.
The nurse lightly strokes the sides of a client's abdomen, above and below the umbilicus. For which reflex is the nurse testing?
Abdominal Explanation: Abdominal reflexes are assessed by lightly stroking the abdomen on each side, above and below the umbilicus. This evaluates the function of the spinal levels T8-T10 with the upper abdominal reflex and spinal levels T10-T12 with the lower abdominal reflex. The sole of the foot is stroked to assess for the presence of the Babinski reflex. The inner thigh is stroked when assessing the cremasteric reflex in a male client. The ankle is dorsiflexed when assessing for ankle clonus.
What should the nurse assess to test the function of the occipital lobe?
Ability to read Explanation: To assess the function of the occipital lobe, the nurse should test the ability to read. To assess the function of the parietal lobe, the nurse should test for tactile sensation. The function of the temporal lobe is assessed by testing for impulses from the ear. Assessment of the frontal lobe is done by testing the client's communication.
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 Explanation: This is a common description and scenario for absence seizures, which are generally brief (fewer than 10 seconds, "petit mal"). They generally occur without warning and do not have a post-ictal confused state. Pseudoseizures are difficult to diagnose but generally involve dramatic-appearing movements, similar to tonic-clonic seizures. Myoclonus represents a single brief jerk of the trunk and limbs.
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. Explanation: The GCS is a tool for assessing a client's response to stimuli. Scores range from 3 (deep coma) to 15 (normal). Eye opening response: Spontaneous 4 To voice 3 To pain 2 None 1 Best verbal response: Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 None 1 Best motor response: Obeys command 6 Localizes pain 5 Withdraws 4 Flexion 3 Extension 2 None 1 Total 3-15. A score of three indicates deep coma; therefore, the client is unable to verbalize pain level on numerical scale or FACES scale. A client in a coma can still experience pain.
The nurse is assessing an newly admitted client with a seizure disorder. The nurse would asses the client for what?
Aura Explanation: The nurse should assess the client about an aura that forewarns the client of an impending seizure. Lightheadedness, hallucinations and delusions are not associated with seizures.
A nurse is preparing to assess a client's cerebellar function. What aspect of neurological function should the nurse address?
Balance Explanation: Balance and coordination are functions of the pyramidal and extrapyramidal tracts of the motor and cerebellar systems. Remote memory and mental status exam provide information about the client's cognitive ability. Testing for sensation would address issues with specific cranial nerves or problems involving the parietal lobe.
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 Explanation: A wide-based, staggering, unsteady gait and positive Romberg test (client unable to stand with feet together) suggest cerebellar ataxia. Spastic hemiparesis is characterized by a flexed arm held close to the body while the client drags the toes of the leg or circles it stiffly outward and forward. A Parkinsonian gait is a shuffling gait. A scissors gait is a short stiff gait with the thighs overlapping each other with each step.
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 Explanation: Cerebellar ataxia, a wide-based gait with staggering and lurching, is often due to alcohol intake or cerebral palsy. Spastic hemiparesis is usually caused by stroke, not alcohol intoxication. Scissors gait is spastic diplegia associated with bilateral spasticity of the legs. Sensory ataxia is due to cerebral palsy also resulting in a wide-based gait.
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 Explanation: The cerebellum's primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone. The temporal lobe is part of the cerebrum and helps with receiving and interpreting impulses from the ear. The cranial nerves evolve from the brain or brain stem and transmit motor or sensory messages. Deep tendon reflexes are part of the sensory pathway of the spinal cord, which relay an impulse to the motor nerve and then to the muscles.
The nurse is performing the Romberg test. Which of the following indicate a normal finding?
Client stands erect with minimal swaying Explanation: The Romberg test is negative is the client stand erect with minimal swaying with eyes both opened and closed. Balance when walking is not part of the Romberg test.
What should the nurse assess to test the function of the frontal lobe?
Communication Explanation: Assessment of the frontal lobe is done by testing the client's communication. To assess the function of the parietal lobe, the nurse should test for tactile sensation. The function of the temporal lobe is assessed by testing for impulses from the ear. To assess the function of the occipital lobe, the nurse should test the ability to read.
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 Explanation: 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.
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. Explanation: When testing motor function ask the client to smile, frown and wrinkle forehead, show teeth, puff out cheeks, and purse the lips.
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 Explanation: 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 documenting assessment of the nervous system, a nurse should keep in mind what important principle?
Describe the response Explanation: When documenting assessment data on the nervous system, it is important for the nurse to describe the response rather than labeling the behavior
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. Explanation: A GCS score of 15 is the maximum score indicating the client's neurological status is normal. Therefore, the nurse should document the findings. This information makes all the remaining options incorrect.
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 Explanation: 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.
Characteristics of the 12 cranial nerves include all of the following except that:
Each has motor and sensory functions. Explanation: 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.
When testing the biceps reflex, what type of response should the nurse expect if normal?
Elbow flexes and muscle contracts Explanation: To elicit the biceps reflex, the nurse should ask the client to partially bend the arm at elbow with palm up. The nurse places the thumb over the biceps and strikes the thumb with the reflex hammer. The normal finding with this reflex is the elbow flexes and contraction of the biceps muscle occurs. When assessing the brachioradialis reflex, the normal finding is flexion and supination of the forearm. The other two are not findings elicited with upper extremity reflexes.
A 7-year-old child comes to the clinic with her mother, who states that her daughter is doing poorly in school because she has some kind of "ADD" (attention deficit disorder). The nurse asks the mother what makes her think the child has ADD. The mother says that both at home and at school her daughter just zones out for several seconds and licks her lips. She states it happens at least four to six times an hour. She says this has been happening for about 1 year. After several seconds of lip licking, her daughter seems normal again. She states her daughter 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 Explanation: In an absence seizure there is no tonic-clonic activity. There is a sudden brief lapse of consciousness with blinking, staring, lip smacking, or hand movements that resolve quickly to full consciousness. It is easily mistaken for daydreaming or ADD. Some will try to induce these episodes with hyperventilation.
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) Explanation: The glossopharyngeal nerve (cranial nerve IX) contains sensory fibers for taste on posterior third of tongue and sensory fibers of the pharynx that result in the "gag reflex" when stimulated. The vagus nerve (cranial nerve X) carries sensations from the throat, larynx, heart, lungs, bronchi, gastrointestinal tract, and abdominal viscera and promotes swallowing, talking, and production of digestive juices. The spinal accessory nerve (cranial nerve XI) innervates neck muscles (sternocleidomastoid and trapezius) that promote movement of the shoulders and head rotation and promotes some movement of the larynx. The hypoglossal nerve (cranial nerve XII) innervates tongue muscles that promote the movement of food and talking.
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?
Health history Explanation: 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.
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 Explanation: Hopping on one foot is often impossible for the older adult because of decreased flexibility and strength and may place the client at risk. The nurse needs to ensure the client's safety by standing close by, especially with tandem walking and Romberg's testing because some older clients may have difficulty with maintaining balance. However, these tests would not be omitted. Older clients may have a slow uncertain gait. Testing the client's gate would not be omitted.
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 Explanation: The hypothalamus controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions. It maintains overall autonomic control. The medulla, part of the brain stem, controls the cardiac, respiratory, vomiting, and vasomotor centers, dealing with autonomic (involuntary) functions of breathing, blood pressure, and heart rate. The brain stem also contains the pons and midbrain. The cerebral cortex is the covering of the cerebrum. Its role is in memory, attention, and consciousness.
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 Explanation: Instructing the client to flex and extend the right elbow is assessing strength, which is a part of the motor system assessment. Instructing the client to state the current date and place is part of the mental status assessment. Instructing the client to smile and close the eyes is part of the cranial nerve assessment.
What is the level of the spinal cord associated with the knee (patellar) deep tendon reflex?
L2 to L4 Explanation: The spinal segments associated with the knee reflex are L2, L3, and L4.
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 Explanation: The nurse should perform the assessment of the nervous system from a level of higher cerebral integration to a level of lower 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 Explanation: 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 Explanation: Weakness made worse with repeated effort and improved with rest suggests myasthenia gravis.
When testing sensory function of the trigeminal nerve (CN V), which of the following sensations would the nurse assess?
Pain and light touch Explanation: The sensory aspects of CN V are assessed for by testing pain sensation (confirmed by temperature sensation) and light touch.
A client has sustained nerve damage as a result of an automobile accident and has lost the ability to sense position, vibration, and fine touch. Which neural pathway should the nurse suspect to be damaged?
Posterior columns Explanation: Sensations of pain, temperature, and crude and light touch travel by way of the spinothalamic tract, whereas sensations of position, vibration, and fine touch travel by way of the posterior columns. The motor neurons of the pyramidal tract carry impulses to muscles and produce voluntary movements that involve skill and purpose. The extrapyramidal tract conducts impulses to the muscles related to maintenance of muscle tone and body control.
The client is diagnosed with a peripheral neuropathy. The nurse knows that often the first sensation lost in a peripheral neuropathy is what?
Vibration Explanation: Vibration sense is often the first sensation to be lost in a peripheral neuropathy.
Which area of the brain integrates the understanding of spoken and written words?
Wernicke's area Explanation: Wernicke's area integrates the understanding of spoken and written words, while Broca's area regulates verbal expression and writing ability. The basal ganglia controls voluntary motor movements, cognition, and emotion. The cerebrum is the part of the brain that contains the cerebral cortex, hippocampus, basal ganglia, and olfactory bulb.
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 Explanation: A normal reflex response is documented as being +2. A diminished reflex response is documented as being +1. A 0 is no reflex response. A +3 is a brisker than average response. A +4 is a very brisk response.
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. Explanation: Cranial nerve VII is the facial cranial nerve and is responsible for facial movements such as facial expressions. Clenching the teeth is associated with cranial nerve V, the trigeminal nerve. The nurse should instruct the client to cover one eye if assessing cranial nerves III, IV, and VI otherwise, oculomotor, trochlear, abducens, respectively. Smelling coffee beans would assist in assessing cranial nerve I, the olfactory nerve.
Where do the cell bodies of the lower motor neurons lie?
Spinal cord Explanation: 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.
The nurse documents "Romberg test positive" on a client's medical record. What did the nurse most likely assess in this client?
Swaying Explanation: A positive Romberg test is when the client sways and moves the feet apart to prevent falling. The Romberg test is not used to assess gait, hand grasps, or the brachial reflex.
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. Explanation: CN VIII is the acoustic nerve; function is thus tested by assessing the client's hearing. Shoulder shrugging tests CN XI; frowning and closing the eyes depend on CN VII. CN I is tested by assessing the client's ability to identify smells.
The nurse plans to test which cranial nerve when testing an elderly client's hearing status?
VIII Explanation: Cranial nerve VIII contains sensory fibers for hearing and balance.
A client is concerned about tripping when walking and feeling uncoordinated. Which part of the brain might be causing this client's symptoms?
cerebellum Explanation: The cerebellum lies at the base of the brain, coordinates all movements and helps maintain the body upright in space. The brainstem regulates respiratory and cardiac function and includes the reticular activating system (RAS), and the midbrain, pons, and medulla oblongata. The frontal lobe is responsible for higher intellectual function, speech production, and ipsilateral motor control. The parietal lobe is the primary somatic sensory area.
The cerebrum is divided into right and left hemispheres, which are joined together by the
corpus callosum. Explanation: The cerebrum is divided into the right and left cerebral hemispheres, which are joined by the corpus callosum—a bundle of nerve fibers responsible for communication between the hemispheres.
The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the
glossopharyngeal. Explanation: The glossopharyngeal nerve contains sensory fibers for taste on posterior third of tongue and sensory fibers of the pharynx that result in the gag reflex when stimulated.
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 Explanation: A complete neurologic examination consists of evaluating the following five areas: mental status, cranial nerves, motor and cerebellar systems, sensory system, and reflexes.
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
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. Explanation: A neuro check includes the following assessment points: level of consciousness, pupillary checks, movement and strength of extremities, sensation in extremities, and vital signs.
What task should a nurse ask a client to perform to assess the function of cranial nerve XI?
shrug shoulders against resistance Explanation: The function of cranial nerve XI can be assessed by asking the client to shrug his or her shoulders against resistance. Asking the client to move the tongue from side to side assesses function of the hypoglossal nerve, Cranial nerve XII. 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 diencephalon of the brain consists of the
thalamus and hypothalamus. Explanation: The diencephalon lies beneath the cerebral hemispheres and consists of the thalamus and hypothalamus.