NURS 114 Exam 1 chapter 25 (Neurological system) prepU

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

During assessment, the nurse notes the client has limited movement of his lower extremities and sways when standing with feet together. The nurse identifies that the client is at risk for what?

Falls

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

False.

The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the

Glossopharyngeal

The nurse is tapping the spine for the level of vertebral pain. The nurse is testing the dermatomes.

True

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 neurological examination, which question would be most appropriate to ask?

"Can you tell me where you are right now?" The nurse should only assess for orientation to date and place when conducting a mental status assessment as part of the neurological examination. Asking details about mood, history of psychiatric disorders, and fluctuations in emotions is better placed when conducting a full mental status assessment, not as part of the screening neurological assessment.

The nurse is providing teaching to a client with type 1 diabetes. When providing information about reducing the risk of diabetic neuropathy, the nurse should be sure to include which point?

"Effective blood glucose regulation can prevent this problem." Maintaining optimal glycemic control can prevent or delay the onset of diabetic neuropathy.

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" It is important to ask the client to walk across the room and walk back first because this will reveal deficits in the gait.

What should the nurse assess to test the function of the occipital lobe?

Ability to read

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.

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. When testing motor function ask the client to smile, frown and wrinkle forehead, show teeth, puff out cheeks, and purse the lips.

What should the nurse assess to test the function of the frontal lobe?

Communication

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 (area responsible for speech)

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. A wide-based, staggering, unsteady gait and positive Romberg test (client unable to stand with feet together) suggest cerebellar ataxia

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 cerebellum's primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone.

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. Delirium in an acute onset of confusion related to an underlying cause such as medication, disease or traumatic event.

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

Depression. Low self-esteem and body image problems may lead to depression and changes in role functions.

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. Glasgow Coma Scale of 15 is the maximum score, so the nurse only needs to document the findings, no need for further actions.

Upon reviewing the client's medical record, the nurse finds the client has left ptosis. The nurse would assess the client for what?

Drooping of the left eye. Ptosis is drooping of an eyelid

A nurse is planning care for a client who has been diagnosed with restless leg syndrome. Which intervention is the most effective for temporary relief of the symptoms?

Exercising the legs

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)

During morning report the nurse learns that an assigned client needs assistance with ambulation because of spastic hemiparesis. What should the nurse expect when ambulating with this client?

Half of one side of the body drags and a flex of the arm close to the body (the side that's dragging)

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. Hopping on one foot is often impossible for the older adult because of decreased flexibility and strength and may place the client at risk.

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 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.

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 (assesses strength which is part of the motor system)

A nurse is performing a test of cranial nerve XII (hypoglossal) on an elderly client. When the client protrudes her tongue for the test, the tongue moves in and out uncontrollably. Which of the following should the nurse most suspect?

Intentional tremor

What is the level of the spinal cord associated with the knee (patellar) deep tendon reflex?

L2 to L4

The nurse is caring for an adult client who suffers from a spinal cord hemisection due to a tumor. The client is unable to feel pain or temperature changes below the level of the tumor. What other symptoms should the nurse teach the family to expect the client to experience?

Loss of position sense, vibration, and motor function on same side of the body

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 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.

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 assessing a client exhibiting dystonic movements. The nurse should review the client's medications from home to check whether he is taking which medications that may cause the dystonia?

Psychiatric medications. Dystonia is commonly due to the use of psychiatric medications, resulting in slow, involuntary movement of the trunk and larger muscles. These movements may also be accompanied by twisted postures.

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. 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.

What task should a nurse ask a client to perform to assess the function of cranial nerve XI?

Shrug shoulders against resistance

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. Cranial nerve VII is the facial cranial nerve and is responsible for facial movements such as facial expressions.

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

The nurse documents "Romberg test positive" on a client's medical record. What did the nurse most likely assess in this client?

Swaying

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?

Sympathetic Nervous System

A nurse is preparing to offer a community education session on anxiety. Which part of the nervous system should the nurse include in the discussion?

Sympathetic nervous system

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. CN VIII is the acoustic nerve which prompts assessment of hearing.

The nurse is assessing a client after a fall. What could indicate damage to the spinal cord?

Tingling. Injury to the spinal cord could manifest by loss of sensation, tingling or burning.

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

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

Which of the following assessment techniques should the nurse use to determine a client's stereognosis?

With the client's eyes closed, place a coin or key in hand and ask him or her to identify the object. Stereognosis is the ability to identify an object by feeling it.

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. Spastic muscle tone is noted with involvement of the corticospinal motor tract.

While assessing the pupils of a hospitalized adult client, the nurse observes that the client's pupils are dilated to 6 mm. The nurse suspects that the client is exhibiting signs of

oculomotor nerve paralysis. Dilated pupil (6-7 mm) can indicate oculomotor nerve paralysis.