Nursing Neurological System
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?" "Can you tell me about your mood today?" "Do you have a history of psychotic disorder?" "Do you feel like crying often?"
"Can you tell me where you are right now?"
What instruction should a nurse give a client when having trouble eliciting a response from testing the patellar deep tendon reflex? "Place your hands together, lock your fingers, and squeeze." "Close your eyes and imagine you are somewhere else." "Clench your teeth and breathe slowly and deeply." "Tighten the thigh muscles of the opposite leg."
"Place your hands together, lock your fingers, and squeeze."
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? "Hop on one spot." "Walk across the room and back." "Walk heel to toe." "Walk on your toes then on your heels."
"Walk across the room and back."
What should the nurse assess to test the function of the occipital lobe? Communication Impulses from the ear Ability to read Tactile sensation
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? Myoclonus Pseudoseizure Tonic-clonic Absence
Absence
A client has an injury that affects the posterior sensory nerve columns of the spinal cord. Which of the following will the nurse most likely find during the examination of the sensory system? (Select all that apply.) Alteration in the perception of position Loss of depth perception Alteration in temperature sense Changes in the perception of vibration Change in pain perception
Alteration in the perception of position Changes in the perception of vibration
A nurse is preparing to assess a client's cerebellar function. What aspect of neurological function should the nurse address? Remote memory Sensation Mental status exam Balance
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? Medulla oblongata Broca's area Occipital lobe Temporal lobe
Broca's area
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? Spastic hemiparesis Foot drop gait Parkinsonian gait Cerebellar ataxia
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? Scissors gait Parkinsonian gait Cerebellar ataxia Spastic hemiparesis
Cerebellar ataxia
The nurse documents "Romberg test positive" on a client's medical record. What did the nurse most likely assess in this client? Unsteady gait Poor brachial reflex Weak hand grasps Swaying
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 Scissors movement Spastic Hemiparesis Sensory ataxia
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? Basal ganglia disease Cerebellar disease Brainstem disease Cerebral disease
Cerebellar disease
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? Temporal lobe Deep tendon reflexes Cranial nerves Cerebellum
Cerebellum
The nurse is performing the Romberg test. Which of the following indicate a normal finding? Client prevents himself from falling Client maintains balance when walking Client sways when eyes are closed Client stands erect with minimal swaying
Client stands erect with minimal swaying
What should the nurse assess to test the function of the frontal lobe? Impulses from the ear Ability to read Communication Tactile sensation
Communication
A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment? Neurologic system Coordination Cardiac function Vital signs
Coordination
As adults age, peripheral nerve function and impulse conduction decrease. What is the result of this decrease? Decreased proprioception Decreased cognitive function Increased myelinization Increased need for sleep
Decreased proprioception
A client cannot differentiate between sharp and dull pain sensations when a nurse tests with a safety pin. What is an appropriate action by the nurse? Try another object and test only the upper dermatomes Strike a tuning fork and place it on the top of one foot Use a wisp of cotton to test light touch sensation Determine the ability to differentiate hot and cold temperatures
Determine the ability to differentiate hot and cold temperatures
A client has a disorder of the hypothalamus. The nurse recognizes that this structure is found in which area of the brain? Cerebellum Diencephalon Cerebrum Brain stem
Diencephalon
A client has a disorder of the hypothalamus. The nurse recognizes that this structure is found in which area of the brain? Cerebrum Diencephalon Cerebellum Brain stem
Diencephalon
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. Ask the client to open eyes on command. Re-assess in 15 minutes. Notify the healthcare provider.
Document the findings.
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? Dominant side will be more coordinated than nondominant side As the client repeats the maneuver, movements will be less accurate Most clients will hesitate before touching the nose to check their position Uncoordinated movements can be expected in the elderly
Dominant side will be more coordinated than nondominant side
Upon reviewing the client's medical record, the nurse finds the client has left ptosis. The nurse would assess the client for what? Swelling of the optic nerve Drooping of the left eye Drooping of the left side of the mouth Loss of visual fields on the left
Drooping of the left eye
When testing the biceps reflex, what type of response should the nurse expect if normal? Elbow flexes and muscle contracts Elbow extends and muscle contracts Forearm flexes and supinates Forearm adducts and wrist rotates
Elbow flexes and muscle contracts
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? Stroke Falls Pressure ulcers Impaired mobility
Falls
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? Simple partial seizure (Jacksonian) Complex partial seizure Generalized tonic-clonic seizure Generalized absence seizure
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? Hypoglossal (XII) Glossopharyngeal (IX) Vagus (X) Spinal accessory (XI)
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? Hypoglossal (XII) Vagus (X) Spinal accessory (XI) Glossopharyngeal (IX)
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? Vagus (X) Glossopharyngeal (IX) Hypoglossal (XII) Spinal accessory (XI)
Glossopharyngeal (IX)
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? Pupillary reaction Level of consciousness Health history Glasgow coma scale
Health history
The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on possibly omitting from the exam? Tandem walking Gait Hop on one foot Romberg
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? Cerebral cortex Medulla Hypothalamus Brain stem
Hypothalamus
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? I II V III
III
What should the nurse assess to test the function of the temporal lobe?
Impulses from the ear
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? Focus on the hammer striking the knee Positions the arms for assessing reflexes Increase reflex activity Keeps the knee in position
Increase reflex activity
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 Exaggerated; indicator of possible upper motor neuron lesion Present but decreased Normal
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 smile Instruct the client to flex and extend the right elbow Instruct the client to state the current date and place Ask the client to close the eyes
Instruct the client to flex and extend the right elbow
A client reports that she is experiencing a tremor when she reaches for things. This worsens as she nears the "target." When the examiner asks the client to hold out her hands, no tremor is apparent. What type does this most likely represent? Intention Postural Nervous Resting
Intention
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? Cerebrovascular accident Intentional tremor Peripheral nerve disease Injury of the central spinal cord
Intentional tremor
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? Injury of the central spinal cord Cerebrovascular accident Peripheral nerve disease Intentional tremor
Intentional tremor
What is the level of the spinal cord associated with the knee (patellar) deep tendon reflex? T9 and T10 S1 T11 and T12 L2 to L4
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 Cranial nerves, motor/cerebellar, sensory, reflexes, mental status Reflexes, sensory, motor/cerebellar, cranial nerves, mental status Motor/cerebellar, sensory, reflexes, cranial nerves, mental status
Mental status, cranial nerves, motor/cerebellar, sensory, reflexes
What task should a nurse ask a client to perform to assess the function of cranial nerve XII? Swallow water Move the tongue from side to side Shrug shoulders against resistance Water in heel-to-toe fashion
Move the tongue from side to side
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 Parkinson disease Lyme disease Ischemic stroke
Myasthenia gravis
The nurse suspects that a client is experiencing meningitis. Which assessment finding caused the nurse to make this clinical determination? Hips and knees relaxed Neck flexes to the chest Pain and hip flexion when the neck is flexed Pain behind the knees when fully extended
Pain and hip flexion when the neck is flexed
When testing sensory function of the trigeminal nerve (CN V), which of the following sensations would the nurse assess? Proprioception and extinction Pain and light touch Dull touch and vibration Vibration and stereognosi
Pain and light touch
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? Anti-hypertensive medications Lipid lowering medications Oral hypoglycemic medications Psychiatric medications
Psychiatric medications
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? Lipid lowering medications Anti-hypertensive medications Psychiatric medications Oral hypoglycemic medications
Psychiatric medications
A nurse is working with a client who suffered nerve damage during surgery for removal of a tumor. The client, who is an artist, lost fine motor control in his hands and can no longer manipulate a paintbrush. Which neural pathway should the nurse suspect to be damaged? Spinothalamic tract Pyramidal tract Posterior columns Extrapyramidal tract
Pyramidal tract
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. Eating a high-sodium diet Maintaining a healthy weight Quitting smoking Regularly exercising Following a sedentary lifestyle
Quitting smoking Regularly exercising Maintaining a healthy weight
What functions are attributed to sensory impulses? (Select all that apply.)
Regulation of internal autonomic functions Body position in space Conscious sensation
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. Cover one eye. Smell coffee beans. Clench the teeth.
Smile.
The nurse is conducting a neurological assessment on an adult. Which findings indicate a need for further evaluation? (Select all that apply.) Active knee jerk when patellar tendon is tapped lightly Snout reflex when tapping a tongue blade across the lips Palmar grasping response when palmar stimulation applied Involuntary flexion of distal joint of thumb and index finger when nail on third finger is tapped Sucking movement of the lips when the lips are stroked with light touch
Snout reflex when tapping a tongue blade across the lips Involuntary flexion of distal joint of thumb and index finger when nail on third finger is tapped Sucking movement of the lips when the lips are stroked with light touch Palmar grasping response when palmar stimulation applied
The nurse observes the client's pupils as one very large and one very small. What should the nurse suspect is occurring with the client? Temporal lobe herniation Structural damage in the midbrain Cocaine use Damage to the sympathetic pathways in the hypothalamus
Temporal lobe herniation
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. Ask the client to shrug both shoulders upward against the examiner's hands. Ask the client to raise his or her eyebrows, frown, and close both eyes tightly. Test the client's ability to identify a familiar smell with his or her eyes closed.
Test the client's hearing for lateralization and bone and air conduction.
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? Vagus Trigeminal Facial Glossopharyngeal
Trigeminal
The nurse is tapping the spine for the level of vertebral pain. The nurse is testing the dermatomes. True False
True
Which action by a nurse demonstrates the correct technique to use the reflex hammer? Strike the tendon then palpate for a response Use rapid wrist movement and strike the tendon Tap the tendon gently to avoid pain and tingling Instruct the client to tense the muscles before striking
Use rapid wrist movement and strike the tendon
Which of the following assessment techniques should the nurse use to determine a client's stereognosis? With the client's eyes closed, trace a number on the client's hand and ask him or her to identify the number. Briefly touch a point on the client's skin and ask the client to open his or her eyes and point to the place touched. Using two ends of an open paper clip, touch two points on the client's finger pad simultaneously and identify the minimal distance that the client can discriminate between the points. With the client's eyes closed, place a coin or key in hand and ask him or her to identify the object.
With the client's eyes closed, place a coin or key in hand and ask him or her to identify the object.
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 open the mouth and say "ah." note the presence of a gag reflex. ask the client to purse the lips. observe the client swallow a sip of water.
ask the client to purse the lips.
A client is concerned about tripping when walking and feeling uncoordinated. Which part of the brain might be causing this client's symptoms? cerebellum frontal lobe brainstem parietal lobe
cerebellum
The cerebrum is divided into right and left hemispheres, which are joined together by the diencephalon. pons. medulla oblongata. corpus callosum.
corpus callosum.
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 hallucinations. delirium. schizophrenia. depression.
depression.
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?
dragging feet holding bladdder
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? resting the legs taking pain medication exercising the legs taking antidepressant medication
exercising the legs
The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the glossopharyngeal. hypoglossal. vagus. trigeminal.
glossopharyngeal.
The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the glossopharyngeal. trigeminal. hypoglossal. vagus.
glossopharyngeal.
The portion of the brain that rims the surfaces of the cerebral hemispheres forming the cerebral cortex is the gray matter. diencephalon. brainstem. cerebellum.
gray matter.
A client reports resting and skipping exercise during a holiday from work. Which part of the nervous system is controlling this client's behavior? central parasympathetic sympathetic cranial nerves
parasympathetic
A client is in the emergency room with what could be a lumbar injury. Which deep tendon reflex would be most appropriate to test? supinator patellar ankle triceps
patellar
The nurse is doing a neurologic screening examination. The nurse should include some aspect of which areas? Select all that apply. sensory system motor system mental status reflexes cardiovascular system cranial nerves
sensory system motor system mental status reflexes cranial nerves
The hypothalamus is responsible for regulating memory. nerve impulses. sleep cycles. eye reflexes.
sleep cycles.
Sensations of temperature, pain, and crude and light touch are carried by way of the posterior tract. extrapyramidal tract. corticospinal tract. spinothalamic tract.
spinothalamic tract.
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? autonomic nervous system peripheral nervous system sympathetic nervous system somatic nervous system
sympathetic nervous system
What should the nurse assess to test the function of the parietal lobe? communication impulses from the ear ability to read tactile sensation
tactile sensation
The diencephalon of the brain consists of the pons and brainstem. thalamus and hypothalamus. cerebellum and midbrain. medulla oblongata and cerebrum.
thalamus and hypothalamus.
