Weber Chapter 25
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 about your mood today?" "Do you feel like crying often?" "Do you have a history of psychotic disorder?" "Can you tell me where you are right now?"
"Can you tell me where you are right now?"
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? "You will be able to observe symptoms of this problem early on." "Testing for this problem will involve having blood tests only." "Pain is the only sensation associated with this problem." "Effective blood glucose regulation can prevent this problem."
"Effective blood glucose regulation can prevent this problem."
When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as being at highest risk? 68-year-old African American male with hypertension 55-year-old Caucasian male who has two beers a week 42-year-old Caucasian woman who smokes 35-year-old African American who has sleep apnea
68-year-old African American male with hypertension
The nurse lightly strokes the sides of a client's abdomen, above and below the umbilicus. For which reflex is the nurse testing?
Abdominal
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? Pseudoseizure Absence Tonic-clonic Myoclonus
Absence
A client reports the feeling of being unsteady when walking. What is an appropriate action by the nurse to assess for a problem with gait and balance? Instruct the client to walk across the floor and note the swinging of the arms Ask the client to walk in a heel-to-toe fashion and watch for an unsteady gait Have the client stretch out the arms and bring one finger at a time to the nose Tell the client to stand with arms at the sides and note the presence of swaying
Ask the client to walk in a heel-to-toe fashion and watch for an unsteady gait
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 Temporal lobe Medulla oblongata Occipital lobe
Broca's area
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? Temporal lobe Medulla oblongata Broca's area Occipital lobe
Broca's area
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? Spastic hemiparesis Parkinsonian gait Cerebellar ataxia Scissors gait
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 Temporal lobe Cranial nerves Deep tendon reflexes
Cerebellum
The nurse is performing the Romberg test. Which of the following indicate a normal finding? Client stands erect with minimal swaying Client sways when eyes are closed Client maintains balance when walking Client prevents himself from falling
Client stands erect with minimal swaying
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? Reinforcement A focal seizure Extinction Clonus
Clonus
What should the nurse assess to test the function of the frontal lobe? Communication Impulses from the ear Tactile sensation Ability to read
Communication
A client has a disorder of the hypothalamus. The nurse recognizes that this structure is found in which area of the brain? Cerebellum Brain stem Cerebrum Diencephalon
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. Notify the healthcare provider. Re-assess in 15 minutes. Ask the client to open eyes on command.
Document the findings.
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? Dorsiflexion of the foot Plantar flexion Dorsiflexion of the great toe and fanning of all toes Flexion of the toes
Dorsiflexion of the great toe and fanning of all toes
Upon reviewing the client's medical record, the nurse finds the client has left ptosis. The nurse would assess the client for what? Loss of visual fields on the left Drooping of the left eye Swelling of the optic nerve Drooping of the left side of the mouth
Drooping of the left eye
When testing the biceps reflex, what type of response should the nurse expect if normal? Forearm adducts and wrist rotates Elbow flexes and muscle contracts Elbow extends and muscle contracts Forearm flexes and supinates
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? Impaired mobility Stroke Pressure ulcers Falls
Falls
The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the trigeminal. vagus. glossopharyngeal. hypoglossal.
Glossopharyngeal
The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on possibly omitting from the exam? Romberg Gait Hop on one foot Tandem walking
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? Medulla Brain stem Hypothalamus Cerebral cortex
Hypothalamus
A nurse cares for a client diagnosed with damage to cranial nerve VII. What should the nurse expect to find in the client? Swelling of the optic nerve Inability to close eyes Drooping of eyelids Loss of visual field
Inability to close eyes
Which of the following assessment findings would lead the nurse to suspect that a client has Bell's palsy? Inability to detect sharp and dull stimuli Muscle spasm of the lower face on the affected side Inability to wrinkle the forehead Closure of the affected eye from swelling
Inability to wrinkle the forehead
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 state the current date and place Instruct the client to flex and extend the right elbow Ask the client to close the eyes
Instruct the client to flex and extend the right elbow
The nurse is caring for an adult client who suffers from a spinal cord hemisection due to a tumor. The client is unable to feel pain or temperature changes below the level of the tumor. What other symptoms should the nurse teach the family to expect the client to experience? Loss of all motor function below the level of the lesion Individual nerve damage along the corresponding dermatome Loss of position sense, vibration, and motor function on same side of the body Sensory loss in the periphery in a very diffuse pattern
Loss of position sense, vibration, and motor function on same side of the body
When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence? Motor/cerebellar, sensory, reflexes, cranial nerves, mental status Reflexes, sensory, motor/cerebellar, cranial nerves, mental status Mental status, cranial nerves, motor/cerebellar, sensory, reflexes Cranial nerves, motor/cerebellar, sensory, reflexes, mental status
Mental status, cranial nerves, motor/cerebellar, sensory, reflexes
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? Parkinson disease Myasthenia gravis Lyme disease Ischemic stroke
Myasthenia gravis
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? Oral hypoglycemic medications Lipid lowering medications Psychiatric medications Anti-hypertensive medications
Psychiatric medications
A client's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding? Right knee +3; Left knee +2 Right knee +2; Left knee +1 Right knee +4; Left knee +3 Right knee +1; Left knee 0
Right knee +2; Left knee +1
Where do the cell bodies of the lower motor neurons lie? Motor strip Neuromuscular junction Spinal cord Anterior roots
Spinal cord
A nurse is instructing a client who has recently experienced a transient ischemic attack (TIA) on warning signs of a stroke that the client should be aware of in case they occur and she needs to call 911. Which of the following should the nurse mention? Select all that apply. Sudden severe headache with no known cause Sudden trouble walking, dizziness, loss of balance or coordination Sudden chest pain Sudden confusion, trouble speaking, or understanding speech Sudden numbness or weakness of the face Sudden trouble seeing in one or both eyes
Sudden numbness or weakness of the face Sudden confusion, trouble speaking, or understanding speech Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden severe headache with no known cause
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 Swaying Weak hand grasps
Swaying
A nurse is working with a client who is victim of a shooting. The client has an increased pulse rate and pupil dilation and is clearly in stress. The nurse recognizes the "fight-or-flight" response in this client and understands that this represents an activation of which of the following? Parasympathetic nervous system Central nervous system Somatic nervous system Sympathetic nervous system
Sympathetic nervous system
Which of the following assessments is most likely to provide insight into the function of the client's CN VIII? Test the client's hearing for lateralization and bone and air conduction. Ask the client to raise his or her eyebrows, frown, and close both eyes tightly. Ask the client to shrug both shoulders upward against the examiner's hands. 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.
The nurse plans to test which cranial nerve when testing an elderly client's hearing status? VII VI VIII V
VIII
Which tests are appropriate for a nurse to perform to test cranial nerve VIII? Smile, frown, show teeth, and puff out cheeks Whisper, Rinne, and Weber tests Clench the teeth, light touch, and sharp/dull discrimination Gag reflex, rise of the uvula, and ability to swallow
Whisper, Rinne, and Weber tests
Which of the following assessment techniques should the nurse use to determine a client's stereognosis? With the client's eyes closed, place a coin or key in hand and ask him or her to identify the object. 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.
The nurse is assessing the neurologic system of an adult client. To test the client's motor function of the facial nerve, the nurse should ask the client to purse the lips. ask the client to open the mouth and say "ah." observe the client swallow a sip of water. note the presence of a gag reflex.
ask the client to purse the lips.
The cerebrum is divided into right and left hemispheres, which are joined together by the corpus callosum. diencephalon. medulla oblongata. pons.
corpus callosum.
The nurse is caring for a client in the hospital and identifies the client to be experiencing acute confusion after cardiac surgery. The nurse recognizes this as what?
delirium
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 delirium. hallucinations. depression. schizophrenia.
depression.
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? taking antidepressant medication exercising the legs resting the legs taking pain medication
exercising the legs
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 triceps ankle supinator
patellar
The cerebrospinal fluid cushions the central nervous system (CNS), provides nourishment to the CNS, and coats the brain. transmits impulses. regulates heart rate. removes wastes.
removes wastes.
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? Cover one eye. Clench the teeth. Smell coffee beans. Smile.
smile
A nurse is preparing to offer a community education session on anxiety. Which part of the nervous system should the nurse include in the discussion? sympathetic nervous system peripheral nervous system autonomic nervous system somatic nervous system
sympathetic nervous system
