Chapter 20: The Nervous 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? "Have you noticed any changes in your vision?" "Have you noticed any weakness in your muscles?" "Are you having any dizziness or lightheadedness?" "Do you have trouble hearing people when they talk to you?"

"Are you having any dizziness or lightheadedness?"

The nurse lightly strokes the sides of a client's abdomen, above and below the umbilicus. For which reflex is the nurse testing? Babinski Ankle clonus Cremasteric Abdominal

Abdominal

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

Altered mentation and decreasing level of consciousness

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

Ask a client to identify scents.

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 VII CN II CN I CN IX

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. Cortex Cell body Axon Dendrite Gyrus

Cell body Axon Dendrite

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? Spastic hemiparesis Parkinsonian gait Cerebellar ataxia Scissors gait

Cerebellar ataxia

The nurse is performing the Romberg test. Which of the following indicate a normal finding? Client prevents himself from falling Client stands erect with minimal swaying Client sways when eyes are closed Client maintains balance when walking

Client maintains balance when walking

When explaining how the nurse would test graphesthesia, which of the following would the nurse include? 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. 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 to identify the numbers of points felt when the nurse touches the client with the ends of two applicators at the same time. The nurse will briefly touch the client and the client will need to identify where the touch occurred.

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

What should the nurse assess to test the function of the frontal lobe? Impulses from the ear Tactile sensation Ability to read Communication

Communication

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

Coordination

The nurse notes that a client in bed has the following posture. How should the nurse document this finding? Decorticate rigidity Decerebrate rigidity Early hemiplegia Normal supine posture

Decerebrate rigidity

When assessing deep tendon reflexes in an elderly client what finding would the nurse anticipate? Normal reaction time Increased reaction time Decreased reaction time Absent

Decreased reaction time

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? Dementia Delirium Amnesia Hypoxia

Delirium

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. Notify the healthcare provider. Re-assess in 15 minutes. Ask the client to open eyes on command.

Document the findings.

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

False

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? Vagus (X) Glossopharyngeal (IX) Hypoglossal (XII) Spinal accessory (XI)

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? Gait Tandem walking Hop on one foot Romberg

Hop on one foot

What should the nurse assess to test the function of the temporal lobe? Impulses from the ear Ability to read Communication Tactile sensation

Impulses from the ear

What is the level of the spinal cord associated with the knee (patellar) deep tendon reflex? S1 L2 to L4 T11 and T12 T9 and T10

L2 to L4

Which of these factors should a nurse include when teaching about risk reduction for cerebrovascular accidents (CVA) to a group of middle-aged adults within the community? Select all that apply. Increase estrogen levels Reduce smoking Limit alcohol to 1 drink per day for women and 2 for men Lower blood pressure Increase protein intake

Limit alcohol to 1 drink per day for women and 2 for men Lower blood pressure

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? Lyme disease Ischemic stroke Myasthenia gravis Parkinson disease

Myasthenia gravis is caused by a breakdown in the normal communication between nerves and muscles.

Which of the following would lead the nurse to suspect meningeal irritation? Hips and knees remain relaxed and motionless when neck is flexed Reports of decreased pain with flexion of the hips and knees Pain and flexion of the hips and knees with neck flexion Discomfort behind the knee with full extension of the leg

Pain and flexion of the hips and knees with neck flexion

A 60-year-old retired seamstress comes to the office reporting decreased sensation in her hands and feet. She states that she began to have the problems in her feet 1 year ago but now it has started in her hands also. She also complains of some weakness in her grip. She has had no recent illnesses or injuries. Her past medical history consists of having type 2 diabetes for 20 years. She now takes insulin and oral medications for her diabetes. She has been married for 40 years. She has two healthy children. Her mother has Alzheimer's disease and coronary artery disease. Her father died of a stroke and also had diabetes. She denies any tobacco, alcohol, or drug use. On examination she has decreased deep tendon reflexes in the patellar and Achilles tendons. She has decreased sensation of fine touch, pressure, and vibration on both feet. She has decreased two-point discrimination on her hands. Her grip strength and her plantar and dorsiflexion strength are decreased. Where is the disorder of the peripheral nervous system in this client? Peripheral polyneuropathy Neuromuscular junction Spinal root and nerve Anterior horn cell

Peripheral polyneuropathy there will be distal extremity symptoms before proximal symptoms. There will be weakness and atrophy and decreased sensory sensations. There is often the classic glove-stocking distribution pattern of the lower legs and hands. Causes include diabetic neuropathy, as in this case, alcoholism, and vitamin deficiencies.

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 Eating a high-sodium diet Maintaining a healthy weight Following a sedentary lifestyle Regularly exercising

Quitting smoking Maintaining a healthy weight Regularly exercising

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 tremor 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 tremor is most likely? Postural Resting Intention

Resting tremors occur when the hands are literally at rest, such as sitting in the lap. These are slow, fine tremors, such as the pill-rolling seen in Parkinson's disease, which this patient most likely has. Decreased arm swing with ambulation is one of the earliest objective findings of Parkinson's disease.

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 Swaying Unsteady gait

Swaying

Which of the following assessments is most likely to provide insight into the function of the client's CN VIII? 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. Test the client's ability to identify a familiar smell with his or her eyes closed. Ask the client to raise his or her eyebrows, frown, and close both eyes tightly.

Test the client's hearing for lateralization and bone and air conduction.

he 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 experiences pain during neck flexion and extension. The client moves her feet apart to prevent herself from falling. 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.

A client presents to the emergency room after being hit in the face with a baseball. The health care provider orders vision testing to be performed to assess the intactness of the cranial nerves. The nurse should prepare to test which cranial nerves? Select all that apply. Olfactory Trochlear Oculomotor Trigeminal Abducens

Trochlear Oculomotor Abducens

Which tests are appropriate for a nurse to perform to test the cranial nerve VIII? Whisper test, Rinne, and Weber Smile, frown, show teeth, and puff out cheeks Gag reflex, rise of the uvula, ability to swallow Clench the teeth, light touch, sharp/dull discrimination

Whisper test, Rinne, and Weber

Which assessment procedure should a nurse institute to test a client for stereognosis? 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, 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

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

The nurse is preparing to test the sensory cranial nerves. The nerves being tested include (Select all that apply.) acoustic hypoglossal optic olfactory trochlear

acoustic olfactory optic

A client is concerned about tripping when walking and feeling uncoordinated. Which part of the brain might be causing this client's symptoms? frontal lobe cerebellum brainstem parietal lobe

cerebellum

The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the hypoglossal. glossopharyngeal. vagus. trigeminal.

glossopharyngeal.

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 ankle triceps supinator

patellar

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

thalamus and hypothalamus.