PrepU ch.25 assessing neurologic system
The nurse is tapping the spine for the level of vertebral pain. The nurse is testing the dermatomes. -True -False
-True Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 589. Chapter 25: Assessing Neurologic System - Page 589
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. -Difficulty following instructions -Slurred speech -Impaired vision -Orientation x 3 -Hypotension
-Difficulty following instructions -Slurred speech -Impaired vision Explanation: Signs and symptoms of a stroke that would be found during a neurological assessment include difficulty following instructions, slurred speech and impaired vision. The client may or may not be oriented x 3 and the nurse would expect to find the client hypertensive. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 577. Chapter 25: Assessing Neurologic System - Page 577
The nurse is doing a neurologic screening examination. The nurse should include some aspect of which areas? Select all that apply. -mental status -cranial nerves -motor system -sensory system -reflexes -cardiovascular system
-mental status -cranial nerves -motor system -sensory system -reflexes Explanation: A complete neurologic examination consists of evaluating the following five areas: mental status, cranial nerves, motor and cerebellar systems, sensory system, and reflexes. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 576. Chapter 25: Assessing Neurologic System - Page 576
When the nurse is assessing a client's mental status as part of the neurological examination, which question would be most appropriate to ask? a."Can you tell me where you are right now?" b."Do you feel like crying often?" c."Do you have a history of psychotic disorder?" d."Can you tell me about your mood today?"
a. "Can you tell me where you are right now?" Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 576,579. Chapter 25: Assessing Neurologic System - Page 576,579
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? a."Effective blood glucose regulation can prevent this problem." b."You will be able to observe symptoms of this problem early on." c."Testing for this problem will involve having blood tests only." d."Pain is the only sensation associated with this problem."
a. "Effective blood glucose regulation can prevent this problem." Explanation: Maintaining optimal glycemic control can prevent or delay the onset of diabetic neuropathy. The progression of neuropathy is slow and often asymptomatic. In addition to blood tests, clients will be assessed using the Lower Extremity Amputation Prevention (LEAP) test which helps detect the loss of protective sensation. Pain is not the only sensation associated with neuropathy. Clients can also experience lowered or lost reflexes which can often be protective against injury that can lead to infection. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.
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? a."Walk across the room and back." b."Walk heel to toe." c."Walk on your toes then on your heels." d."Hop on one spot."
a. "Walk across the room and back." Explanation: It is important to ask the client to walk across the room and walk back first because this will reveal deficits in the gait. This, in turn, will allow the nurse to focus the assessment. Asking the client to walk across the room and then back assists the nurse in observing posture, balance, swinging of the arms, and movements of the legs. Asking the client to walk heel to toe is called "tandem walking." It would be appropriate to instruct the client to do this to determine if there is ataxia that was not previously obvious. Asking the client to walk on the toes then on the heels assists the nurse in assessing for plantar flexion of the ankles as well as for balance. The nurse should instruct the client to do this if problems with balance are noted initially. Asking the client to hop in place provides information about the client's position sense and cerebellar function. If the nurse is not yet aware whether the client is at risk for falls, this assessment should be left until the quality of gait has been assessed. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 587. Chapter 25: Assessing Neurologic System - Page 587
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? a.Cerebellar ataxia b.Parkinsonian gait c.Spastic hemiparesis d.Foot drop gait
a. Cerebellar ataxia Explanation: Cerebellar ataxia is recognized by the wide-based and staggering gait. The Romberg test will be positive. This gait can be seen in persons with cerebellar disease or alcohol or drug intoxication. The characteristic abnormality in Parkinson's disease is the shuffling gait with a stooped-over posture and flexion of the hips and knees. Spastic hemiparesis presents with the arm flexed and held close to the body while the client drags the toes and circles the leg outward and forward. Foot drop is seen when the client lifts the foot and knee high with each step, then slaps the foot hard to the ground. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 603. Chapter 25: Assessing Neurologic System - Page 603
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? a.Cerebellar disease b.Cerebral disease c.Brainstem disease d.Basal ganglia disease
a. Cerebellar disease Explanation: In cerebellar disease, movements are clumsy, unsteady, and inappropriately varying in their speed, force, and direction. The finger may initially overshoot its mark, but finally reaches it fairly well, termed dysmetria. An intention tremor may appear toward the end of the movement. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 603. Chapter 25: Assessing Neurologic System - Page 603
The nurse is performing the Romberg test. Which of the following indicate a normal finding? a.Client stands erect with minimal swaying b.Client sways when eyes are closed c.Client prevents himself from falling d.Client maintains balance when walking
a. Client stands erect with minimal swaying Explanation: The Romberg test is negative is the client stand erect with minimal swaying with eyes both opened and closed. Balance when walking is not part of the Romberg test. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 587. Chapter 25: Assessing Neurologic System - Page 587
The nurse plans to test which cranial nerve when testing an elderly client's hearing status? a.VIII b.VII c.VI d.V
a. VIII Explanation: Cranial nerve VIII contains sensory fibers for hearing and balance. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 571. Chapter 25: Assessing Neurologic System - Page 571
During an admission assessment, the nurse notes that the client has diabetes with peripheral neuropathy. What finding would the nurse expect to find? a.Decreased sensation in the feet b.Severe pain in legs c.Open sores on legs d.Bluish discoloration
a. Decreased sensation in the feet Explanation: A client with peripheral neuropathy would have decreased sensation in extremities. Pain, discoloration, and open sores would not be expected. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 590. Chapter 25: Assessing Neurologic System - Page 590
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? a.Delirium b.Hypoxia c.Dementia d.Amnesia
a. Delirium Explanation: Delirium in an acute onset of confusion related to an underlying cause such as medication, disease or traumatic event. Dementia occurs over a time, amnesia is a loss of memory and hypoxia may be a cause of delirium. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 575. Chapter 25: Assessing Neurologic System - Page 575
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? a.Hypothalamus b.Brain stem c.Cerebral cortex d.Medulla
a. Hypothalamus Explanation: 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. The medulla, part of the brain stem, controls the cardiac, respiratory, vomiting, and vasomotor centers, dealing with autonomic (involuntary) functions of breathing, blood pressure, and heart rate. The brain stem also contains the pons and midbrain. The cerebral cortex is the covering of the cerebrum. Its role is in memory, attention, and consciousness. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 569. Chapter 25: Assessing Neurologic System - Page 569
What should the nurse assess to test the function of the temporal lobe? a.Impulses from the ear b.Communication c.Tactile sensation d.Ability to read
a. Impulses from the ear Explanation: The function of the temporal lobe is assessed by testing for impulses from the ear. To assess the function of the parietal lobe, the nurse should test for tactile sensation. Assessment of the frontal lobe is done by testing the client's communication. To assess the function of the occipital lobe, the nurse should test the ability to read. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 568. Chapter 25: Assessing Neurologic System - Page 568
While testing a client's deep tendon reflexes the nurse asks the client to perform the action shown (sitting at edge with legs dangling off the table, putting hands together). What is the purpose of this action? a.Increase reflex activity b.Keeps the knee in position c.Focus on the hammer striking the knee d.Positions the arms for assessing reflexes
a. Increase reflex activity Explanation: The client is performing the technique of reinforcement. It works if the client's reflexes are absent by using isometric contraction of other muscles to increase reflex activity. This action is not being done to keep the knee in position. It does not help with focus on the hammer when striking the knee. This is not the position to assess the arm reflexes. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 594. Chapter 25: Assessing Neurologic System - Page 594
When testing sensory function of the trigeminal nerve (CN V), which of the following sensations would the nurse assess? a.Pain and light touch b.Dull touch and vibration c.Vibration and stereognosis d.Proprioception and extinction
a. Pain and light touch Explanation: The sensory aspects of CN V are assessed for by testing pain sensation (confirmed by temperature sensation) and light touch. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 571, 582. Chapter 25: Assessing Neurologic System - Page 571, 582
A nurse cares for an elderly client with right side hemiplegia and expressive aphasia. Which deficit should the nurse expect to find in the client? a.Slow speech with appropriate meaning b.Rapid speech with no meaning c.Inability to recognize familiar objects d.Trouble remembering familiar faces
a. Slow speech with appropriate meaning Explanation: The client diagnosed with right side hemiplegia and expressive aphasia can verbally state wishes. Expressive aphasia is also called Broca's aphasia in which the speech is slowed with difficult articulation but fairly clear meaning. Clients with Wernicke's aphasia have rapid speech with no meaning. Inability to recognize familiar objects is called agnosia. Trouble remembering familiar faces is termed prosopagnosia. Both of these conditions can occur with damage to the temporal and occipital lobes of the brain. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 598. Chapter 25: Assessing Neurologic System - Page 598
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? a.Smile. b.Clench the teeth. c.Cover one eye. d.Smell coffee beans.
a. Smile. Explanation: Cranial nerve VII is the facial cranial nerve and is responsible for facial movements such as facial expressions. Clenching the teeth is associated with cranial nerve V, the trigeminal nerve. The nurse should instruct the client to cover one eye if assessing cranial nerves III, IV, and VI otherwise, oculomotor, trochlear, abducens, respectively. Smelling coffee beans would assist in assessing cranial nerve I, the olfactory nerve. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 583. Chapter 25: Assessing Neurologic System - Page 583
The nurse documents "Romberg test positive" on a client's medical record. What did the nurse most likely assess in this client? a.Swaying b.Unsteady gait c.Weak hand grasps d.Poor brachial reflex
a. Swaying Explanation: A positive Romberg test is when the client sways and moves the feet apart to prevent falling. The Romberg test is not used to assess gait, hand grasps, or the brachial reflex. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 587. Chapter 25: Assessing Neurologic System - Page 587
A client with a diagnosis of type 1 diabetes is admitted to the hospital with acute symptomatic seizures. Given the client's underlying condition, what would be the most likely cause of this type of seizure? a.hyperglycemia b.ventricular tachycardia c.syncope d.headache
a. hyperglycemia Explanation: Acute symptomatic seizures can be caused by metabolic insults related to high or low blood glucose. There is no evidence to support that ventricular tachycardia would cause an acute symptomatic seizure. Syncope is often the cause of lightheadedness or fainting due to loss of cerebral perfusion. Although head trauma can be a causal factor in acute symptomatic seizures, there is no evidence to associate headache as an underlying cause of acute symptomatic seizures. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.
What task should a nurse ask a client to perform to assess the function of cranial nerve XI? a.shrug shoulders against resistance b.move tongue side to side c.swallow water d.walk in heel-to-toe fashion
a. shrug shoulders against resistance Explanation: The function of cranial nerve XI can be assessed by asking the client to shrug his or her shoulders against resistance. Asking the client to move the tongue from side to side assesses function of the hypoglossal nerve, Cranial nerve XII. The nurse asks the client to swallow water to assess the function of cranial nerves IX and X. Asking the client to walk in heel-to-toe fashion helps in assessment of balance. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 585. Chapter 25: Assessing Neurologic System - Page 585
When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as being at highest risk? a.42-year-old Caucasian woman who smokes b.68-year-old African American male with hypertension c.55-year-old Caucasian male who has two beers a week d.35-year-old African American who has sleep apnea
b. 68-year-old African American male with hypertension Explanation: Risk factors include older adulthood (risk doubling each decade after age 55), male sex, African American race, hypertension, smoking, chronic alcohol intake (more than three drinks per day), and sleep apnea among others. In the clients listed, the 68-year-old African American male with hypertension has the greatest risk due to his age, race, and hypertension. The other clients would be at risk, but the risk would be less. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 578. Chapter 25: Assessing Neurologic System - Page 578
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? a.A focal seizure b.Clonus c.Extinction d.Reinforcement
b. Clonus Explanation: Clonus is a sustained rhythmical "beating" that correlates with CNS disease and hyperreflexia. A focal seizure could be virtually ruled out by stopping the stimulus and watching the phenomenon stop. Extinction is a term applied to sensory testing in which one side of a simultaneous, bilateral stimulus is not felt because of damage to the cortex. Reinforcement applies to enhancing reflex examination by distracting the client (e.g., pulling his hands against each other). Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 580. Chapter 25: Assessing Neurologic System - Page 580
What should the nurse assess to test the function of the frontal lobe? a.Impulses from the ear b.Communication c.Tactile sensation d.Ability to read
b. Communication Explanation: Assessment of the frontal lobe is done by testing the client's communication. To assess the function of the parietal lobe, the nurse should test for tactile sensation. The function of the temporal lobe is assessed by testing for impulses from the ear. To assess the function of the occipital lobe, the nurse should test the ability to read. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 568. Chapter 25: Assessing Neurologic System - Page 568
A nurse performs a neurologic examination on a client who sustained an injury to the spinal cord. What finding should the nurse expect when stroking the bottom of the client's feet? a.Plantar flexion b.Dorsiflexion of the great toe and fanning of all toes c.Dorsiflexion of the foot d.Flexion of the toes
b. Dorsiflexion of the great toe and fanning of all toes Explanation: An injury to the spinal cord or the brain causes abnormal posturing in the client. This includes dorsiflexion of the great toe and fanning of all toes when the sole of the foot is stroked—a positive Babinski reflex—which is normal in newborns but in adults is an indication of lesions of upper motor neurons or unconscious states resulting from drug and alcohol intoxication, brain injury, or subsequent to an epileptic seizure. In the normal adult, the response to stroking the bottom of the foot is flexion of the toes. Dorsiflexion and plantar flexion are not associated with this reflex. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 595. Chapter 25: Assessing Neurologic System - Page 595
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? a.Instruct the client to state the current date and place b.Instruct the client to flex and extend the right elbow c.Instruct the client to smile d.Ask the client to close the eyes
b. Instruct the client to flex and extend the right elbow Explanation: Instructing the client to flex and extend the right elbow is assessing strength, which is a part of the motor system assessment. Instructing the client to state the current date and place is part of the mental status assessment. Instructing the client to smile and close the eyes is part of the cranial nerve assessment. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 579. Chapter 25: Assessing Neurologic System - Page 579
Which cranial nerve controls pupillary constriction? a.Optic b.Oculomotor c.Trochlear d.Trigeminal
b. Oculomotor Explanation: The oculomotor nerve causes pupillary constriction, opening the eye (lid elevation), and most extraocular movements. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 571. Chapter 25: Assessing Neurologic System - Page 571
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? a.Right knee +1; Left knee 0 b.Right knee +2; Left knee +1 c.Right knee +3; Left knee +2 d.Right knee +4; Left knee +3
b. Right knee +2; Left knee +1 Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 580. Chapter 25: Assessing Neurologic System - Page 580
The nurse observes the client's pupils as shown (left eye dilated pupil and right eye constricted pupil). What should the nurse suspect is occurring with the client? a.Cocaine use b.Temporal lobe herniation c.Structural damage in the midbrain d.Damage to the sympathetic pathways in the hypothalamus
b. Temporal lobe herniation Explanation: A pupil that is fixed and dilated can indicate herniation of the temporal lobe that causes compression of the oculomotor nerve and midbrain. Pupils that are large and reactive are seen in cocaine or other sympathetic nervous system agonist drugs. Pupils that are fixed in mid-position indicate structural damage in the midbrain. Small or pinpoint pupils indicate damage to the sympathetic pathways in the hypothalamus. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 582. Chapter 25: Assessing Neurologic System - Page 582
A client says that an object placed in the hand is a pair of scissors when the object is a paper clip. Which aspect of the client's neurologic system should the nurse identify as being compromised? a.motor b.sensory c.position sense d.responsiveness
b. sensory Explanation: The nurse performed stereognosis which is a technique used to assess the sensory status. Assessment of the motor status includes gait, muscle strength, and muscle tone. Position sense determines if the client has intact proprioception. Responsiveness refers to level of consciousness. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 583. Chapter 25: Assessing Neurologic System - Page 583
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? a.Pseudoseizure b.Tonic-clonic c.Absence d.Myoclonus
c. Absence Explanation: This is a common description and scenario for absence seizures, which are generally brief (fewer than 10 seconds, "petit mal"). They generally occur without warning and do not have a post-ictal confused state. Pseudoseizures are difficult to diagnose but generally involve dramatic-appearing movements, similar to tonic-clonic seizures. Myoclonus represents a single brief jerk of the trunk and limbs. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 573. Chapter 25: Assessing Neurologic System - Page 573
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? a.Temporal lobe b.Occipital lobe c.Broca's area d.Medulla oblongata
c. Broca's area Explanation: The Broca's area is the center that is responsible for speech. The temporal lobe helps with receiving and interpreting impulses from the ear. The occipital lobe influences the ability to read with understanding and is the primary visual receptor center. The medulla oblongata contains the nuclei for the cranial nerves and has centers that control and regulate respiratory function, heart rate and force, and blood pressure. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.
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? a.Try another object and test only the upper dermatomes b.Use a wisp of cotton to test light touch sensation c.Determine the ability to differentiate hot and cold temperatures d.Strike a tuning fork and place it on the top of one foot
c. Determine the ability to differentiate hot and cold temperatures Explanation: If a client cannot correctly differentiate between sharp and dull pain sensations, the nurse should test for temperature sensation. Temperature and pain sensations travel in the lateral spinothalamic tract, thus temperature is only tested if pain sensation is altered. If a client cannot feel pain, feeling a lighter touch is unlikely. Striking a tuning fork and placing it on the top of one foot tests vibratory sensation, not pain or touch. The nurse should not try another object and test on the upper dermatomes, as this would not likely change the results. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 590. Chapter 25: Assessing Neurologic System - Page 590
The nurse performs a neurological assessment and determines the Glasgow Coma Scale (GCS) score is 15. What is the nurse's best action? a.Notify the healthcare provider. b.Re-assess in 15 minutes. c.Document the findings. d.Ask the client to open eyes on command.
c. Document the findings. Explanation: A GCS score of 15 is the maximum score indicating the client's neurological status is normal. Therefore, the nurse should document the findings. This information makes all the remaining options incorrect. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 597, 579. Chapter 25: Assessing Neurologic System - Page 597, 579
Nursing students are doing a class presentation on stroke. What is the term they would use for deficits in speech articulation? a.Aphasia b.Nystagmus c.Dysarthria d.Dystonia
c. Dysarthria Explanation: Deficits in articulation are referred to as dysarthria. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 574. Chapter 25: Assessing Neurologic System - Page 574
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? a.Anti-hypertensive medications b.Lipid lowering medications c.Psychiatric medications d.Oral hypoglycemic medications
c. Psychiatric medications Explanation: 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. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.
A 21-year-old engineering student comes to your office complaining of leg and back pain and of tripping when he walks. He states this started 3 months ago with back and buttock pain but has since progressed to feeling weak in his left leg. He denies any bowel or bladder symptoms. He can think of no specific traumatic incidences, but he was a defensive lineman in high school and junior college. His past medical history is unremarkable. He denies tobacco use or alcohol or drug abuse. His parents are both healthy. On examination he is tender over the lumbar spine and he has a positive straight leg raise on the left. His Achilles tendon deep reflex is decreased on the left. While watching his gait the nurse notices that the client has to pick his left foot up high in order not to trip. What abnormality of gait does he most likely have? a.Sensory ataxia b.Parkinsonian gait c.Steppage gait d.Spastic hemiparesis
c. Steppage gait Explanation: Steppage gait is associated with foot drop, usually secondary to a lower motor neuron disease. This is often seen with a herniated disc. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 603. Chapter 25: Assessing Neurologic System - Page 603
Sensations of temperature, pain, and crude and light touch are carried by way of the... a.extrapyramidal tract. b.corticospinal tract. c.spinothalamic tract. d.posterior tract.
c. spinothalamic tract. Explanation: Sensations of pain, temperature, and crude and light touch travel by way of the spinothalamic tract. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 569. Chapter 25: Assessing Neurologic System - Page 569
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? a.peripheral nervous system b.autonomic nervous system c.sympathetic nervous system d.somatic nervous system
c. sympathetic nervous system Explanation: The sympathetic nervous system mobilizes organs and their functions during times of stress and arousal such as with the experience of anxiety. The peripheral nervous system supplies nerve stimulation to the heart, visceral organs, skin, and the extremities. The autonomic nervous system connects to internal organs and generates autonomic reflex responses. The somatic nervous system regulates muscle movements and response to sensations of touch and pain. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 572. Chapter 25: Assessing Neurologic System - Page 572
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... a."What did you have for breakfast?" b."How old were you when you began working?" c."Can you repeat rose, hose, nose, clothes?" d."Can you repeat brown, chair, textbook, tomato?"
d. "Can you repeat brown, chair, textbook, tomato?" Explanation: Remote memory (past dates and historical accounts) may be impaired in cerebral cortex disorders. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.
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? a.Spastic hemiparesis b.Parkinsonian gait c.Scissors gait d.Cerebellar ataxia
d. Cerebellar ataxia Explanation: A wide-based, staggering, unsteady gait and positive Romberg test (client unable to stand with feet together) suggest cerebellar ataxia. Spastic hemiparesis is characterized by a flexed arm held close to the body while the client drags the toes of the leg or circles it stiffly outward and forward. A Parkinsonian gait is a shuffling gait. A scissors gait is a short stiff gait with the thighs overlapping each other with each step. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 603. Chapter 25: Assessing Neurologic System - Page 603
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? a.Spastic Hemiparesis b.Scissors movement c.Sensory ataxia d.Cerebellar ataxia
d. Cerebellar ataxia Explanation: Cerebellar ataxia, a wide-based gait with staggering and lurching, is often due to alcohol intake or cerebral palsy. Spastic hemiparesis is usually caused by stroke, not alcohol intoxication. Scissors gait is spastic diplegia associated with bilateral spasticity of the legs. Sensory ataxia is due to cerebral palsy also resulting in a wide-based gait. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 603. Chapter 25: Assessing Neurologic System - Page 603
The nurse is assessing the neurological status of an unconscious client. The nurse should use which assessment scale? a.Norton b.Braden c.Morse d.Glasgow
d. Glasgow Explanation: An appropriate scale to assess the neurological status of an unconscious client is the Glasgow Coma Scale (GCS). The Norton and Braden scales are used to assess skin. The Morse Fall scale is used to assess the risk for falls. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 579. Chapter 25: Assessing Neurologic System - Page 579
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? a.Peripheral nerve disease b.Cerebrovascular accident c.Injury of the central spinal cord d.Intentional tremor
d. Intentional tremor Explanation: Older adults may experience intentional tremors (tremors that occur with intentional movements). This may be seen with extending the hands, head nodding for "yes or no," or extending one's tongue, which may protrude back and forth. Such tremors are not associated with disease, but they may cause embarrassment or emotional distress. Fasciculations and atrophy of the tongue may be seen with peripheral nerve disease. Injury of the central spinal cord is associated with extremity weakness. Sudden numbness and weakness of the muscles of the face, arms, and legs are associated with cerebrovascular accident (stroke). Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 575. Chapter 25: Assessing Neurologic System - Page 575
When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence? a.Cranial nerves, motor/cerebellar, sensory, reflexes, mental status b.Motor/cerebellar, sensory, reflexes, cranial nerves, mental status c.Reflexes, sensory, motor/cerebellar, cranial nerves, mental status d.Mental status, cranial nerves, motor/cerebellar, sensory, reflexes
d. Mental status, cranial nerves, motor/cerebellar, sensory, reflexes Explanation: The nurse should perform the assessment of the nervous system from a level of higher cerebral integration to a level of lower reflexes. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 576. Chapter 25: Assessing Neurologic System - Page 576
The nurse suspects that a client is experiencing meningitis. Which assessment finding caused the nurse to make this clinical determination? a.Hips and knees relaxed b.Neck flexes to the chest c.Pain behind the knees when fully extended d.Pain and hip flexion when the neck is flexed
d. Pain and hip flexion when the neck is flexed Explanation: Pain and flexion of the hips and knees is a positive Brudzinski sign that suggests meningeal inflammation. If the hips and knees remain relaxed and the neck is able to be flexed to the chest, the client is not demonstrating signs of meningeal irritation. Pain behind the knees when fully extended is a normal finding in some people. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 596. Chapter 25: Assessing Neurologic System - Page 596
Which tests are appropriate for a nurse to perform to test cranial nerve VIII? a.Gag reflex, rise of the uvula, and ability to swallow b.Clench the teeth, light touch, and sharp/dull discrimination c.Smile, frown, show teeth, and puff out cheeks d.Whisper, Rinne, and Weber tests
d. Whisper, Rinne, and Weber tests Explanation: Cranial nerve VIII is the acoustic/vestibulocochlear nerve, which is associated with the client's ability to hear. The nurse should perform the whisper test and, using the tuning fork, the Rinne and Weber tests. The gag reflex, rise of the uvula, and ability to swallow are tests to assess cranial nerves IX (glossopharyngeal) and X (vagus). Asking the client to smile, frown, show teeth, and puff out the cheeks assesses the function of cranial nerve VII (facial). Clenching the teeth, identifying light touch, and discriminating between sharp and dull stimuli are assessments of cranial nerve V (trigeminal). Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 584. Chapter 25: Assessing Neurologic System - Page 584
The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the... a.vagus. b.hypoglossal. c.trigeminal. d.glossopharyngeal.
d. glossopharyngeal. Explanation: The glossopharyngeal nerve contains sensory fibers for taste on posterior third of tongue and sensory fibers of the pharynx that result in the gag reflex when stimulated. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 571. Chapter 25: Assessing Neurologic System - Page 571
A client reports resting and skipping exercise during a holiday from work. Which part of the nervous system is controlling this client's behavior? a.central b.sympathetic c.cranial nerves d.parasympathetic
d. parasympathetic Explanation: The parasympathetic nervous system conserves energy and resources during times of rest and relaxation. The central nervous system consists of the brain and spinal cord. The sympathetic nervous system mobilizes organs and their functions during times of stress and arousal. The cranial nerves emerge from within the cranial vault through skull foramina and canals to structures in the head and neck. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 572. Chapter 25: Assessing Neurologic System - Page 572
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... a.deep coma. b.severe impairment. c.no verbal response. d.some impairment.
d. some impairment. Explanation: The points associated with the Glasgow Coma Scale are determined to assess levels of consciousness and coma. Points are allotted for each of the 3 areas: eye opening, verbal response and motor responses. A score of 13 indicates some impairment. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.
The diencephalon of the brain consists of the... a.pons and brainstem. b.medulla oblongata and cerebrum. c.cerebellum and midbrain. d.thalamus and hypothalamus.
d. thalamus and hypothalamus. Explanation: The diencephalon lies beneath the cerebral hemispheres and consists of the thalamus and hypothalamus. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 569. Chapter 25: Assessing Neurologic System - Page 569
