Chapter 25: Neurologic System PQ
generalized absence seizure
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?
trigeminal
A client blinks when the right eye is lightly touched with a cotton wisp. Which cranial nerve should the nurse document as being intact?
trigeminal
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?
patellar
A client is in the emergency room with what could be a lumbar injury. Which deep tendon reflex would be most appropriate to test?
"are you having any dizziness or lightheadedness?"
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?
parasympathetic
A client reports resting and skipping exercise during a holiday from work. Which part of the nervous system is controlling this client's behavior?
depression
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
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?
determine the ability to differentiate hot and cold temperatures
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 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?
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?
III
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?
Broca's area
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?
XI
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?
balance
A nurse is preparing to assess a client's cerebellar function. What aspect of neurological function should the nurse address?
increased or brisk, but not pathologic
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?
ask the client about the presence of contact lenses
A nurse is testing a client's corneal reflex but notices that the reflex appears to be reduced. The client is otherwise alert and oriented, with no signs of neurologic degeneration. What is an appropriate action by the nurse?
sympathetic nervous system
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?
false
After testing deep tendon reflexes, the nurse documents 2+. The nurse should evaluate further.
health history
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?
decreased proprioception
As adults age, peripheral nerve function and impulse conduction decrease. What is the result of this decrease?
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?
spinothalamic tract
Sensations of temperature, pain, and crude and light touch are carried by way of the
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
corpus callosum
The cerebrum is divided into right and left hemispheres, which are joined together by the
myasthenia gravis
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?
glossopharyngeal
The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the
thalamus and hypothalamus
The diencephalon of the brain consists of the
cerebellum
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?
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?
swaying
The nurse documents "Romberg test positive" on a client's medical record. What did the nurse most likely assess in this client?
assess for nonverbal signs
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?
diabetic peripheral neuropathy
The nurse is assessing a 51-year-old morbidly obese client who is seeking care for the recent loss of sensation in his feet and toes. The client also complains of intermittent burning and tingling in his feet that radiate up his legs. For which of the following health problems should the nurse first assess?
aura
The nurse is assessing an newly admitted client with a seizure disorder. The nurse would asses the client for what?
cerebellar disease
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?
"Can you repeat brown, chair, textbook, tomato?"
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
sensation in extremities
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
delirium
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?
mental status, cranial nerves, motor system, sensory system, reflexes
The nurse is doing a neurologic screening examination. The nurse should include some aspect of which areas? Select all that apply.
clonus
The nurse is examining a child with severe cerebral palsy. On sudden movement of the child's foot dorsally, a sustained "beating" of the foot against the nurse's hand ensues. What does this represent?
client stands erect with minimal swaying
The nurse is performing the Romberg test. Which of the following indicate a normal finding?
hop on one foot
The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on possibly omitting from the exam?
document the findings
The nurse performs a neurological assessment and determines the Glasgow Coma Scale (GCS) score is 15. What is the nurse's best action?
V
The nurse performs the action shown when assessing a client. Which cranial nerve is the nurse assessing in this client? (cotton ball on eye region)
VIII
The nurse plans to test which cranial nerve when testing an elderly client's hearing status?
absent two-point discrimination on the lower right arm
The nurse suspects that a client has a lesion in the sensory cortex. Which assessment finding did the nurse use to make this clinical decision?
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?
drooping of the left eye
Upon reviewing the client's medical record, the nurse finds the client has left ptosis. The nurse would assess the client for what?
communication
What should the nurse assess to test the function of the frontal lobe?
ability to read
What should the nurse assess to test the function of the occipital lobe?
tactile sensation
What should the nurse assess to test the function of the parietal lobe?
shrug shoulders against resistance
What task should a nurse ask a client to perform to assess the function of cranial nerve XI?
move the tongue from side to side
What task should a nurse ask a client to perform to assess the function of cranial nerve XII?
dominant side will be more coordinated than nondominant side
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?
decreased reaction time
When assessing deep tendon reflexes in an elderly client what finding would the nurse anticipate?
basal ganglia system
When assessing the client, the nurse notes bradykinesia. The nurse would know that this abnormality is caused by damage to what?
68-year-old African American male with hypertension
When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as being at highest risk?
mental status, cranial nerves, motor/cerebellar, sensory, reflexes
When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence?
pain and light touch
When testing sensory function of the trigeminal nerve (CN V), which of the following sensations would the nurse assess?
elbow flexes and muscle contracts
When testing the biceps reflex, what type of response should the nurse expect if normal?
oculomotor
Which cranial nerve controls pupillary constriction?
Test the client's hearing for lateralization and bone and air conduction
Which of the following assessments is most likely to provide insight into the function of the client's CN VIII?
hypothalamus
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?
whisper, Rinne, and Weber tests
Which tests are appropriate for a nurse to perform to test cranial nerve VIII?
difficulty following instructions, slurred speech, impaired vision
While performing a neurological assessment on a 56-year-old male, the nurse identifies the client may be experiencing a stroke. What symptoms would the nurse identified? Select all that apply.
increase reflex activity
While testing a client's deep tendon reflexes the nurse asks the client to perform the action shown. What is the purpose of this action? (elbows out, arms flat across body and hands interlocked)
