HA. Chap 25

The nurse is assessing CN V ( trigeminal nerve ) in a newly admitted client . What instruction should the nurse provide to the client during this phase of assessment ?

" Clench your teeth together tightly . "

During a routine follow up visit , an older adult client asks the nurse , " I've noticed that my sense of smell has decreased over the years and I'm concerned about the cause . " What is the nurse's best response ?

" Over time the sense of smell decreases in some people , and this is normal . "

The nurse assesses brisk reflexes in a client during a neurological assessment . How would the nurse document this finding ?

3+

When a nursing instructor is describing the peripheral nervous system to a group of students , the instructor would explain that there are how many pairs of spinal nerves ?

31

When evaluating a client's risk for cerebrovascular accident , which client would the nurse identify as being at highest risk ?

68 - year - old African American male with hypertension

The nurse is performing the Romberg test on a client during a neurological assessment How should the nurse perform this test ? Place the following steps in the correct order .

A. Ask the client to stand erect with arms at the sides and the feet together . B. Ask the client to close the eyes for 20 seconds . C. Ask the client to stand on one foot and bend the knee on which the client is standing . D. Ask the client to hop on one foot .. E. Repeat on the opposite side .

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 .

A. Pain B. Temperature E. Light touch

The nurse is testing a client for Kernig sign . Which finding ( s ) should cause the nurse to suspect meningeal irritation ? Select all that apply .

A. Pain when the knee is extended B. Resistance to knee extension

The nurse is assessing a 39 - year - old woman who has a 20 - year history of cigarette smoking . When reviewing the client's current medication administration record , what drug would the nurse identify as increasing the woman's risk of stroke ?

An oral contraceptive

A nurse is preparing to assess the cranial nerves of a client . The nurse is about to test CN I. What would the nurse do ?

Ask a client to identify scents .

The nurse is assessing a client who has a history of recurrent Bell palsy . Which findings suggest to the nurse that the client is experiencing a recurrence of this condition ? Select all that apply .

B. Inability to wrinkle the forehead E. Inability to close the eyes

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 ?

Balance and coordination .

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 ?

CNI

During the Romberg test , a client is unable to stand with the feet together and demonstrates a wide - based , staggering , unsteady gait . The nurse would identify this as which of the following ?

Cerebellar ataxia

While the nurse is assessing a client's coordination , the client exhibits uncoordinated , jerky movements and is unable to touch either finger to the nose . Which condition should the nurse suspect ?

Cerebellar disease

When explaining how the nurse would test graphesthesia , which of the following would the nurse include ?

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

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

A client has sustained an injury to the cerebellum . Which area would be the primary area for assessment ?

Coordination

While the nurse is performing as assessment of the eyes for a client , the nurse notes that one of the client's pupils is dilated and unresponsive to light . Which condition should the nurse suspect ?

Cranial nerve III ( oculomotor ) damage

What would the nurse most likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident ?

Difficulty speaking

When preparing to test a client for meningeal irritation , what would the nurse to do first ?

Ensure no injury to the cervical spine

The nurse is teaching a group of students about the brain and spinal cord and asks the students , " What does the brain stem control ? " Which response by the students requires further follow - up by the nurse ?

Equilibrium

When assessing a client's deep tendon reflexes , which technique would be most appropriate for the nurse to use ?

Hold the reflex hammer between the thumb and index finger .

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 of the following assessment findings would lead the nurse to suspect that a client has Bell palsy ?

Inability to wrinkle the forehead

A nurse is having difficulty eliciting a patellar reflex during a client's neurological assessment . What would be most appropriate for the nurse to have the client do ?

Lock the fingers together and pull against each other .

The nurse has placed her hands behind the client's head and flexed the client's neck forward as far as the client can tolerate . During the test , the client experiences leg pain and bends his knees . This assessment finding is suggestive of what health problem ?

Meningitis

Which of the following would lead the nurse to suspect meningeal irritation ?

Pain and flexion of the hips and knees with neck flexion

What would be most appropriate for the nurse to do when assessing motor function of a client's trigeminal nerve ?

Palpate temporal and masseter muscles while client clenches the teeth .

Examination of a client's gait reveals that the client is stooped over when walking and that he slowly shuffles . As well , the client maintains a stiff posture when walking . The nurse should document what type of gait ?

Parkinsonian gait

The emergency department nurse's rapid assessment of a young adult client admitted unresponsive reveals fixed , constricted pupils bilaterally . The nurse should consider what possible cause for this assessment finding ?

Recent narcotic use

A client complains of headaches each morning that disappear after getting out of bed . Which of the following would be most appropriate for the nurse to do ?

Refer the client for immediate follow - up .

During a routine follow - up visit , the nurse is assessing a client who reports a sudden severe headache and inability to see out of the left eye . What would be most appropriate for the nurse to do ?

Refer the client for immediate medical follow - up .

The nurse is obtaining the health history of a young adult client . During the interview , the client tells the nurse , " I banged my head pretty good when I was snowboarding last weekend . " The client states that he did not subsequently seek care . What is the nurse's most appropriate action ?

Refer the client for medical assessment and possible treatment .

An adult client has asked the nurse about actions that she can take to reduce her future risk of stroke . What health promotion activity should the nurse prioritize ?

Smoking cessation

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 moves her feet apart to prevent herself from falling .

The nurse performing a point localization test on a client during al neurological assessment . How shoulld the nurse perform this test ?

The client will close the eyes . The nurse will then gently touch the client , and the client will identify where the touch occurred .

The nurse is conducting a focused neurological assessment of an 81 - year - old client . When analyzing the assessment data , the nurse should be aware of what age - related neurological change ?

Tremors accompanying intentional movements

A nurse is testing a client's deep tendon reflex . The nurse taps the tendon above the olecranon process . The nurse is assessing which reflex ?

Triceps

When assessing cranial nerves IX and X , what would the nurse consider as a normal finding ?

Uvula and soft palate rising bilaterally on phonation