Questions from the Point part 2

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?"

A client is newly diagnosed with myasthenia gravis. What should the nurse expect to assess in this client?

intact deep tendon reflexes The client with myasthenia gravis will have intact deep tendon reflexes. Muscle fasciculations do not occur. The muscles are not paralyzed or atrophied in myasthenia gravis.

A nurse performs a two-point discrimination test on a client who was in an automobile accident to assess for the presence of a lesion of the sensory cortex. The nurse touches the client's body at various sites on his right side with the two points of EKG calipers. Which finding, stated as the distance between the two points at which the client can no longer distinguish the two points as separate, would indicate an abnormal response on the part of the client?

20 mm on the dorsal hand Normal two-point discrimination findings on the right side include the following: 6 mm at the fingertips, 15 mm on the dorsal hand, 45 mm on the chest, and 40 mm on the upper arm. Thus, the finding of 20 mm on the dorsal hand is abnormal and may indicate a lesion of the sensory cortex.

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 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. Footdrop is seen when the client lifts the foot and knee high with each step, then slaps the foot hard to the ground.

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

Communication 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.

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

The nurse is conducting a neurological assessment on an adult. Which findings indicate a need for further evaluation? (Select all that apply.)

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 An active knee jerk when the patellar tendon is tapped lightly is a normal reflexive response. A grasping response is associated with dementia and diffuse brain impairment. The snout reflex is an abnormal finding in adults and is elicited by tapping a tongue blade across the lips and observing for pursing of the lips.The Hoffman sign is abnormal and is elicited when tapping on the nail on the 3r or 4th finger eliciting flexion of the distal joint. The rooting reflex is abnormal in an adult and is elcitied by stroking the lips with light touch and the client then moves the mouth toward the stimulus.

A patient is in the emergency room with what could be a lumbar injury. Which deep tendon reflex would be most appropriate to test?

patellar

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 points associated with the Glascow 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.