Prepu questions chapter 19,20
A nursing instructor is discussing mental health assessments with students. In what situations would the instructor tell the students an acute mental health assessment is necessary?
A situation that involves danger of harm to self or others
The nurse is assessing a client using the Glasgow Coma Scale following an acute hypoglycemic episode and obtains a score of 14. The nurse interprets this as indicating which of the following?
Alert and oriented
Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve?
Palpates temporal and masseter muscles while client clenches teeth.
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.
Assessing orientation to person, place, and time helps determine: ability to understand analogies. state of consciousness. attention span. abstract reasoning.
state of consciousness.
The nurse assesses an older adult using the Mini-Mental Status Exam. The total score obtained is 24. Which interpretation by the nurse is correct?
The client is cognitively intact.
The nurse is performing a point localization test on a client during a neurological assessment. How should 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.
Which clients are most at risk for depressive symptoms Married clients Divorced clients Females Males Chronically ill clients
Divorced clients Females Chronically ill clients
The awareness of body position is known as: graphesthesia two-point discrimination. proprioception. stereognosis.
proprioception.
A nurse is preparing to assess a client's cerebellar function. What aspect of neurological function should the nurse address?
Balance
What is the level of the spinal cord associated with the knee (patellar) deep tendon reflex?
L2 to L4
The portion of the brain that rims the surfaces of the cerebral hemispheres forming the cerebral cortex is the
gray matter.
A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment?
Coordination
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."
The nurse plans to administer the CAGE Self-Assessment tool on a client. The nurse explains to the client how and when the tool is used by stating
"It is a short tool used to identify people at risk for substance use disorder. It consists of four questions."
Which question is appropriate for a nurse to ask a client to assess the client's recent memory?
"What did you eat for breakfast today?"
Which question asked by the nurse assesses judgment of the client?
"What will you do if you feel the need to use cocaine again?"
The nurse is preparing to assess a client's remote memory. Which question would be most appropriate for the nurse to use?
"When did you get your first job?"
You are assessing the deep tendon reflexes of a 28-year-old man. Your examination reveals that the patient's reflexes are normal. You would document this finding as _____. 2+ 3+ 4+ 1+
2+
The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following?
3+
While conducting an assessment the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating?
confabulation
The nurse has asked the client to stand for 30 seconds with his arms forward, palms up, and eyes closed. The client pronates (turns downward) his left palm during the test. What health problem should the nurse first suspect in light of this assessment finding?
A lesion in the corticospinal tract
What should the nurse assess to test the function of the occipital lobe?
Ability to read
The nurse is assessing a client using the Glasgow Coma Scale following an acute hypoglycemic episode and obtains a score of 14. The nurse interprets this as indicating
Alert and oriented
The nurse observes a client's entire body posture to be somewhat stiff, with his shoulders elevated upward toward the ears. The nurse would interpret this to indicate that the client is experiencing
Anxiety
On assessment of a client, the nurse finds that the client has difficulty in producing and understanding language. How should the nurse document this finding in the client's record?
Aphasia
A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. Which of the following would the nurse do?
Ask a client to identify scents.
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?
Ask the client about the presence of contact lenses
A client reports the feeling of being unsteady when walking. What is an appropriate action by a nurse to assess for a problem with gait and balance?
Ask the client to walk in a heel to toe fashion and watch for an unsteady gait
The nurse notes that an older adult client is wearing multiple layers of clothing on a warm fall day. What would be the nurse's priority assessment at this time?
Asking whether the client often feels cold
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?
Assess for nonverbal signs.
While conversing with a 42-year-old client, the nurse notes the client's tendency to repeatedly wink and shrug his shoulders at irregular intervals. The movements do not appear to correlate with the client's conversation. How should the nurse best follow up this observation?
Assess the client's medication regimen and history of recreational drug use.
When assessing the mental status of a 67-year-old woman, the nurse detects some difficulty with free-flow of thought and following directions. Which of the following would the nurse do first?
Assess the client's vision and hearing.
A 72-year-old man comes to the clinic with his daughter for a follow-up visit after a recent hospitalization. He had been admitted to the local hospital for speech problems and weakness in his right arm and leg. On admission his MRI showed a small stroke. The client was in rehabilitation for 1 month following his initial presentation. He is now walking with a walker and has good use of his arm. His daughter complains, however, that everyone is still having trouble communicating with him. The nurse asks the client how he thinks he is doing. Although it is hard to make out his words, the nurse believes the client's answer is "well . . . fine . . . doing . . . okay." His prior medical history involved high blood pressure and coronary artery disease. He is a widower and retired handyman. He has three children who are healthy. He denies tobacco, alcohol, or drug use. He has no other current symptoms. On examination he is in no acute distress but does seem embarrassed when it takes him so long to answer. Blood pressure is 150/90; other vital signs are normal. Other than his weak right arm and leg, physical examination findings are unremarkable. What disorder of speech does he have?
Broca's aphasia
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
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?
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
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 nurse is performing the Romberg test. Which of the following indicate a normal finding?
Client stands erect with minimal swaying
A nurse performs a focused neurological assessment on a client who was involved in a motor vehicle accident. The initial Glasgow Coma Scale (GCS) at the scene was recorded as 11. On arrival at the hospital, the nurse records the client's GSC as 13. What is the best action of the nurse?
Continue to monitor the client.
A client has a disorder of the hypothalamus. The nurse recognizes that this structure is found in which area of the brain?
Diencephalon
What would the nurse most likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident?
Difficulty speaking
The nurse is admitting a client to the mental health unit with a diagnosis of attempted suicide. Which is the best question for the nurse to ask first?
Do you have any thoughts of wanting to harm or kill yourself?
A teenage client tried to commit suicide by slashing both wrists after the client's significant other broke up with the client. The client was admitted to a behavioral unit 1 week ago. The client has responded well to treatment and is looking forward to going home. What is the most important client outcome in this situation?
Does not harm self
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
When do you start the mental status portion of the neurologic system examination? During the history-taking process While testing for deep tendon reflexes During assessment of cranial nerves and deep tendon reflexes
During the history-taking process
A 48-year-old grocery store manager comes to the clinic complaining of her head being "stuck" to one side. She says that today she was doing her normal routine when it suddenly felt like her head was being moved to her left and then it just stuck that way. She says it is somewhat painful because she cannot move it back to a normal position. She denies any recent neck trauma. Her past medical history consists of type 2 diabetes and gastroparesis (slow-moving peristalsis in the digestive tract, seen in diabetes). She is taking oral medication for each. She is married with three children. She denies tobacco, alcohol, or drug use. Her father has diabetes and her mother passed away from breast cancer. Her children are healthy. Examination reveals a slightly overweight Hispanic woman appearing her stated age. Her head is twisted grotesquely to her left; otherwise, her examination is normal. What form of involuntary movement does she have?
Dystonia
Which of the following is the most important skill a nurse needs when conducting a mental status assessment?
Effective listening skills
A nurse has been asked to complete a mental status examination of a psychiatric-mental health client. Which of the following is included in this assessment
Evaluation of insight and judgment
A nurse has been asked to complete a mental status examination of a psychiatric-mental health client. Which of the following is included in this assessment?
Evaluation of insight and judgment
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
A 29-year-old woman comes to the office. During history taking, the nurse notices that the client is speaking very quickly and jumping from topic to topic so rapidly that it is difficult to follow her. The nurse can find some connections between ideas, but it is difficult. Which word best describes this thought process?
Flight of ideas
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?
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?
Glossopharyngeal (IX)
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 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
A nurse assesses a client for pupillary response of the eyes finds unilateral dilated pupils that are unresponsive to light or accommodation. The nurse recognizes that which cranial nerve is responsible for the damage of pupillary response?
III
The client has a Glasgow Coma Score of 7. The nurse understands this client is considered to be what?
In coma
How do you test CNXII (Hypoglossal)? Inspect the tongue for wasting tremors and midline movement Inspect the uvula for midline movement Ask patient to swallow Move sides of chin against resistance
Inspect the tongue for wasting tremors and midline movement
As part of assessing the client's level of consciousness, the nurse asks questions related to person, place, and time. Which of these statements is true?
Orientation to time is usually lost first and orientation to person is usually lost last.
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
The nurse is testing for Brudzinski's sign in a newly admitted client. What would indicate meningeal inflammation?
Pain and flexion of the hips and knees
When testing sensory function of the trigeminal nerve (CN V), which of the following sensations would the nurse assess?
Pain and light touch
The client is brought to the clinic by his son, who states, "My father just doesn't seem to be able to function as well as he used to." When assessing this client the nurse is aware that she will be a what?
Patient advocate
A 60-year-old retired seamstress comes to the office reporting decreased sensation in her hands and feet. She states that she began to have the problems in her feet 1 year ago but now it has started in her hands also. She also complains of some weakness in her grip. She has had no recent illnesses or injuries. Her past medical history consists of having type 2 diabetes for 20 years. She now takes insulin and oral medications for her diabetes. She has been married for 40 years. She has two healthy children. Her mother has Alzheimer's disease and coronary artery disease. Her father died of a stroke and also had diabetes. She denies any tobacco, alcohol, or drug use. On examination she has decreased deep tendon reflexes in the patellar and Achilles tendons. She has decreased sensation of fine touch, pressure, and vibration on both feet. She has decreased two-point discrimination on her hands. Her grip strength and her plantar and dorsiflexion strength are decreased. Where is the disorder of the peripheral nervous system in this client?
Peripheral polyneuropathy
The nurse begins the health history with a focus on the client's mental status. Why does the nurse ask for the client's age?
Provides a reference point for psychosocial developmental level
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
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 nurse is conducting an assessment of an elderly client's nervous system. The client mentions that he has experienced decreased taste and scent sensations recently. Which of the following should the nurse do at this point?
Record the findings and proceed with the assessment
The nurse utilizes the Depression Questionnaire on a client who has recently moved to a long-term care facility. The total score is 22. What would the nurse to do next?
Refer for further evaluation.
You are initially evaluating the equilibrium of Ms. Q. You ask her to stand, with her feet together and arms at her sides. She loses her balance. Ms. Q has a positive: Homan sign. McMurray test. Romberg sign. Kernig sign.
Romberg sign.
A 19-year-old college student, Todd, comes to the clinic with his mother, who is concerned that there is something seriously wrong with him. She states that for the past 6 months, her son's behavior has become peculiar, and that he has flunked out of college. Todd denies any recent illness or injuries. His past medical history is remarkable only for a broken foot. His parents are healthy. He has a paternal uncle who had similar symptoms in college. The client admits to smoking cigarettes and drinking alcohol. He also admits to marijuana use but not in the last week. He denies use of any other substances and feelings of depression or anxiety. The nurse does a complete physical examination, which is essentially normal. When the nurse questions the client about how he is feeling, he says that he is worried that his software for creating a better browser has been stolen. He says that he has seen a black van in his neighborhood at night, and he is sure that it is full of computer programmers stealing his work through special gamma waves. The nurse asks why Todd believes they are trying to steal his programs. He replies that the programmers have been telepathing their intents directly into his
Schizophrenia
A 28-year-old book editor comes to the clinic reporting strange episodes. He states that about once a week for the last 3 months his left hand and arm will stiffen and then start jerking. After a few seconds his whole left arm and then his left leg also start to jerk. He denies any loss of consciousness or loss of bowel or bladder control. When the symptoms resolve, his arm and leg feel tired; otherwise, he feels fine. His past medical history is significant for a cyst in his brain that was removed 6 months ago. He is married with two children. His parents are both healthy. Examination shows a scar over the right side of his head, but otherwise his neurological examination is unremarkable. What type of seizure disorder is most likely?
Simple partial seizure (Jacksonian)
The intensive care nurse is working with a client who has increased intracranial pressure secondary to a traumatic brain injury. The nurse is performing the hourly assessment of the client's level of consciousness and observes that the client's eyes are closed. How should the nurse first stimulate the client to assess for arousability
Speak to the client clearly from a close distance.
The client states, "I don't know why God as abandoned me; I am a good person." The nurse suspects the client is at risk for:
Suicide
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
Sympathetic nervous system
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.
How do you test function of the optic nerve? Test for convergence Inspect pupils for size, shape and equality Examine Extra Ocular Movements Test visual acuity by the Snellen chart
Test visual acuity by the Snellen chart
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 begins the physical examination of a newly admitted client by assessing the client's mental status. What is the nurse's best rationale for performing the mental status exam early in the assessment?
The exam can provide clues about the validity of the client's responses now and throughout.
A woman has accompanied her 80-year-old husband to a scheduled clinic visit and expresses concern about subtle declines in his cognition. Which principles would guide the nurse's assessment of the client's mental status?
The nurse must differentiate between age-related changes and the signs and symptoms of
A woman experienced syncope after hearing that her son was severely injured. She became pale and collapsed to the ground without injuring herself. On waking, she states that she felt very warm. She denies any other symptoms. There are no findings on examination. What caused her loss of consciousness?
Vasovagal syncope
When conducting a Romberg test, why does the nurse ask the client to stand feet together with eyes open and then closed?
Vision can compensate for loss of position sense.
As part of a mental status assessment, the nurse asks a client to draw the face of a clock. This will allow the nurse to assess which of the following domains of mental status?
Visual perceptual and constructional ability
The nurse notes that an older client speaks rapidly and uses words that make no sense or communicate any clear meaning. When documenting this finding, the nurse should use which term to describe this client's speech?
Wernicke's aphasia
Which tests are appropriate for a nurse to perform to test the cranial nerve VIII?
Whisper test, Rinne, and Weber
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.
A nurse is providing care for a client who has hepatic encephalopathy secondary to chronic alcohol abuse. The nurse's assessment reveals that the client often provides incorrect answers to assessment questions. The client also makes statements that are not grounded in reality. The nurse should prioritize a care plan for which condition first?
acute confusion
When the nurse asks the client to say "No ifs, ands, or buts," the client tries but is unable to repeat the phrase with fluency. The nurse understands that this may indicate a form of
aphasia
The nurse uses the Mini-Mental State Examination to assess a client. For which reason is this assessment tool most likely used?
dementia
A client known to a health clinic arrives wearing soiled clothing with matted hair and streaks of dirt on the face and hands. What should this client's appearance suggest to the nurse?
depression
The client's daughter asks the nurse why the nurse is asking her mother depression-related questions. The nurse explains that even though the client has symptoms of dementia, the Geriatric Depression Scale is being used because
depression often mimics signs and symptoms of dementia.
The nurse is observing an older adult client dress and groom as part of a mental health assessment. Which finding indicates that the client may need further follow-up related to a cerebral vascular accident (CVA)?
extreme unilateral neglect
The nurse is caring for a client with a history of seizure disorder. The nurse observes the client making severe jerky movements (extending and contracting extremities) and the client loses consciousness. The nurse will identify this as which type of seizure?
generalized seizure
If a nurse suspects that a client is depressed, asking the client about any suicidal thoughts
is important and will not stimulate the thought of suicide
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
A nursing instructor is teaching a group of students about assessing a client's orientation. The instructor determines that the teaching was successful when the students state that the ability to identify which of the following usually is lost first?
time