Deck 58: Nursing Assessment Nervous System

Question 1

Which of the following actions should the nurse implement to assess the functioning of the trigeminal and facial nerves (CN V and VII) in a client?

A)Apply a cotton wisp strand to the cornea.
B)Have the client read a magazine or book.
C)Shine a bright light into the client's pupil.
D)Check for unilateral drooping of the eyelids.

Answer 1

Apply a cotton wisp strand to the cornea.

Question 2

The nurse is preparing a client for a lumbar puncture. Which of the following actions should the nurse implement?

A)Transfer the client to radiology just before the procedure.
B)Help the client to a side lying position before the procedure.
C)Place the client on NPO status for 4 hours before the procedure.
D)Administer a sedative medication 30 minutes before the procedure.

Answer 2

Help the client to a side lying position before the procedure.

Question 3

The nurse is caring for a client who is hospitalized with a possible seizure disorder. To determine the cause of the client's symptoms, the nurse will anticipate the need to teach the client about which of the following tests?

A)Cerebral angiography
B)Evoked potential studies
C)Electromyography (EMG)
D)Electroencephalography (EEG)

Answer 3

Electroencephalography (EEG)

Question 4

The nurse is completing a neurological assessment with a client. Which of the following assessments is the most sensitive indicator of a change in neurological status?

A)Level of consciousness
B)Cognition and thought content
C)Mood and affect
D)General appearance and behaviour

Question 5

Neurological testing of the client indicates impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). Which of the following actions should the nurse include in the plan of care?

A)Insert an oral airway.
B)Withhold oral fluid or foods.
C)Provide highly seasoned foods.
D)Apply artificial tears every hour.

Question 6

The nurse is developing a plan of care for a client with dysfunction of the cerebellum. Which of the following goals of care should the nurse include?

A)Prevent falls.
B)Stabilize mood.
C)Enhance swallowing ability.
D)Improve short-term memory.

Question 7

Aclient has a lesion that affects lower motor neurons. During assessment of the client's lower extremities, which of the following findings should the nurse expect?

A)Spasticity
B)Flaccidity
C)Loss of sensation
D)Hyperactive reflexes

Question 8

The following prescriptions are received for an unconscious client who has just arrived in the emergency department after a head injury caused by an automobile accident. Which of the following prescriptions should the nurse question?

A)Obtain radiographs of the skull and spine.
B)Prepare the client for lumbar puncture.
C)Send for computed tomography (CT) scan.
D)Perform neurologic checks every 15 minutes.

Question 9

Which of the following information about an older-adult client is most important for the admitting nurse to report to the client's health care provider?

A)Triceps reflex response graded at 1/5
B)Recent unintended weight loss of 9.1 kg
C)Client complaint of chronic difficulty in falling asleep
D)Orthostatic drop in systolic blood pressure of 10 mm Hg

Question 10

The nurse notes in the client's medical history that the client has a positive Romberg test. Which of the following nursing diagnoses is appropriate?

A)Acute pain related to physical injury agent (hyper-reflexia and spasm)
B)Risk for falls as evidenced by impaired mobility
C)Risk for autonomic dysreflexia as evidenced by spasm
D)Ineffective thermoregulation related to inactivity

Question 11

Propranolol, a ?-adrenergic blocker that inhibits sympathetic nervous system activity, is prescribed for a client. Which of the following assessments should the nurse monitor?

A)Dry mouth
B)Constipation
C)Slowed pulse
D)Urinary retention

Question 12

After reviewing a client's cerebro-spinal fluid analysis, which of the following results is most important for the nurse to communicate to the health care provider?

A)Specific gravity 1.007
B)Protein 6.5 g/L
C)White blood cell (WBC) count 5 * 10?/L
D)Glucose 2.5 mmol/L

Question 13

The charge nurse is observing a new staff nurse who is assessing a client with a possible spinal cord lesion for sensation. Which of the following actions indicates a need for further teaching about neurological assessment?

A)The new nurse asks the client, "Does this feel sharp?"
B)The new nurse tests for light touch before testing for pain.
C)The new nurse has the client close the eyes during testing.
D)The new nurse uses an irregular pattern to test for intact touch.

Question 14

When caring for a client who has had cerebral angiography, which of the following nursing actions should be included in the plan of care?

A)Ask about headache and photophobia.
B)Keep client NPO until gag reflex returns.
C)Check pulse and blood pressure frequently.
D)Assess orientation to person, place, and time.

Question 15

Which of the following equipment should the nurse obtain to assess vibration sense in a client who has peripheral nerve dysfunction?

A)Sharp pin
B)Tuning fork
C)Reflex hammer
D)Calibrated compass

Question 16

During the neurological assessment, the client cooperates with the nurse's directions to grip with the hands and to move the feet but is unable to respond orally to the nurse's questions. Which of the following diagnoses should the nurse suspect based uponthese findings?

A)A brain stem lesion
B)A temporal lobe lesion
C)Injury to the cerebellum
D)Damage to the frontal lobe

Question 17

Which of the following assessments should the nurse make to test a client's cerebellar function? (Select all that apply.)

A)Assess for graphesthesia.
B)Perform the finger-to-nose test.
C)Observe arm movement with gait.
D)Check ability to push against resistance.
E)Determine ability to sense heat and cold.

Question 18

The nurse is admitting a client with a head injury who is acutely confused. Which of the following actions should the nurse take?

A)Ask family members about the client's health history.
B)Ask leading questions to assist in obtaining health data.
C)Wait until the client is better oriented to ask questions.
D)Obtain only the physiologic neurological assessment data.

Question 19

The nurse is performing a focused assessment on a client with a lesion of the left posterior temporal lobe. Which of the following assessments should the nurse complete?

A)Sensation on the left side of the body
B)Voluntary movement on the right side
C)Reasoning and problem-solving abilities
D)Understanding of written and oral language

Question 20

The nurse is admitting a client with a brain stem infarction. Which of the following assessments is priority?

A)Reflex reaction time
B)Pupil reaction to light
C)Level of consciousness
D)Respiratory rate and rhythm