Ch. 25 Assessing Neurologic 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 screening neurological examination, which question would be most appropriate to ask?
"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."
The nurse lightly strokes the sides of a client's abdomen, above and below the umbilicus. For which reflex is the nurse testing?
Abdominal
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 a client's cerebellar function. What aspect of neurological function should the nurse address?
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
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 nurse is performing the Romberg test. Which of the following indicate a normal finding?
Client stands erect with minimal swaying
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
A client has a disorder of the hypothalamus. The nurse recognizes that this structure is found in which area of the brain?
Diencephalon
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.
When testing the biceps reflex, what type of response should the nurse expect if normal?
Elbow flexes and muscle contracts
After testing deep tendon reflexes, the nurse documents 2+. The nurse should evaluate further.
False
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
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 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
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?
Increased or brisk, but not pathologic
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
What is the level of the spinal cord associated with the knee (patellar) deep tendon reflex?
L2 to 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
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
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
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
During an assessment of the cranial nerves, a client reports spontaneously losing balance. The nurse should focus additional assessment on which cranial nerve?
VIII
When conducting a Romberg test, why does the nurse ask the client to stand feet together with eyes open and then closed?
Vision can compensate for loss of position sense.
A nurse is performing a focused cranial assessment on a client. The nurse observes that the client is unable to shrug their shoulders. The nurse documents this as a dysfunction of which cranial nerve?
XI
What should the nurse assess to test the function of the occipital lobe?
ability to read
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 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 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 client has dysmetria. What would the nurse know this client has?
cerebellar disease
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
The nurse is assessing the neurologic system of a client who has spastic muscle tone. The nurse should explain to the client that spastic muscle tone is associated with impairment to the
corticospinal tract
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
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 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 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 cerebrospinal fluid cushions the central nervous system (CNS), provides nourishment to the CNS, and
removes wastes
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
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
