Question 1

The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination.When striking the Achilles heel and quadriceps muscle,the nurse is unable to elicit a reflex.The nurse's next response should be to:

Accepted Answer

Sometimes the reflex response fails to appear.Documenting the reflexes as absent is inappropriate this soon in the examination.The nurse should try to further encourage relaxation,varying the person's position or increasing the strength of the blow.Reinforcement is another technique to relax the muscles and enhance the response.The person should be asked to perform an isometric exercise in a muscle group somewhat away from the one being tested.For example,to enhance a patellar reflex,the person should be asked to lock the fingers together and pull.

Question 2

The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of "always dropping things and falling down." While testing rapid alternating movements,the nurse notices that the woman is unable to pat both of her knees.Her response is extremely slow and she frequently misses.What should the nurse suspect?

Accepted Answer

When a person tries to perform rapid,alternating movements,responses that are slow,clumsy,and sloppy are indicative of cerebellar disease.The other responses are incorrect.

Question 3

The nurse places a key in the hand of a patient and he identifies it as a penny.What term would the nurse use to describe this finding?

Accepted Answer

Stereognosis is the person's ability to recognize objects by feeling their forms,sizes,and weights.Astereognosis is an inability to identify objects correctly,and it occurs in sensory cortex lesions.Tactile discrimination tests fine touch.Extinction tests the person's ability to feel sensations on both sides of the body at the same point.

Question 4

The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes.When testing her ability to feel the vibrations of a tuning fork,the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally,but she is able to feel vibrations on both patellae.Given this information,what would the nurse suspect?

Accepted Answer

Loss of vibration sense occurs with peripheral neuropathy (e.g.,diabetes and alcoholism).Peripheral neuropathy is worse at the feet and gradually improves as the examiner moves up the leg,as opposed to a specific nerve lesion,which has a clear zone of deficit for its dermatome.The other responses are incorrect.

Question 5

When the nurse is testing the triceps reflex,what is the expected response?

Accepted Answer

The normal response of the triceps reflex is extension of the forearm.The normal response of the biceps reflex causes flexion of the forearm.The other responses are incorrect.

Question 6

The assessment of a 60-year-old patient has taken longer than anticipated.In testing his pain perception,the nurse decides to complete the test as quickly as possible.When the nurse applies the sharp point of the pin on his arm several times,he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this?

Accepted Answer

At least 2 seconds should be allowed to elapse between each stimulus to avoid summation.With summation,frequent consecutive stimuli are perceived as one strong stimulus.The other responses are incorrect.

Question 7

The nurse is caring for a patient who has just had neurosurgery.To assess for increased intracranial pressure,what would the nurse include in the assessment?

Accepted Answer

Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process.These people must be closely monitored for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure.The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness,motor function,pupillary response,and vital signs.

Question 8

In assessing a 70-year-old patient who has had a recent cerebrovascular accident,the nurse notices right-sided weakness.What might the nurse expect to find when testing his reflexes on the right side?

Accepted Answer

Hyperreflexia is the exaggerated reflex observed when the monosynaptic reflex arc is released from the influence of higher cortical levels.This response occurs with upper motor neuron lesions (e.g.,a cerebrovascular accident).The other responses are incorrect.

Question 9

To test for gross motor skill and coordination of a 6-year-old child,which of these techniques would be appropriate? Ask the child to:

Accepted Answer

Normally,a child can hop on one foot and can balance on one foot for approximately 5 seconds by 4 years of age and can balance on one foot for 8 to 10 seconds at 5 years of age.Children enjoy performing these tests.Failure to hop after 5 years of age indicates incoordination of gross motor skills.Asking the child to touch his or her finger to the nose checks fine motor coordination; and asking the child to make "funny" faces tests CN VII.Asking a child to stand on his or her head is not appropriate.

Question 10

During the neurologic assessment of a "healthy" 35-year-old patient,the nurse asks him to relax his muscles completely.The nurse then moves each extremity through full range of motion.Which of these results would the nurse expect to find?

Accepted Answer

Tone is the normal degree of tension (contraction)in voluntarily relaxed muscles.It shows a mild resistance to passive stretching.Normally,the nurse will notice a mild,even resistance to movement.The other responses are not correct.

Question 11

When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed,he starts to sway and moves his feet farther apart.The nurse would document this finding as:

Accepted Answer

Abnormal findings for the Romberg test include swaying,falling,and a widening base of the feet to avoid falling.A positive Romberg sign is a loss of balance that is increased by the closing of the eyes.Ataxia is an uncoordinated or unsteady gait.Homans sign is used to test the legs for deep-vein thrombosis.

Question 12

To assess the head control of a 4-month-old infant,the nurse lifts up the infant in a prone position while supporting his chest.The nurse looks for what normal response? The infant:

Accepted Answer

At 3 months of age,the infant raises the head and arches the back as if in a swan dive.This response is the Landau reflex,which persists until 1 years of age (see Figure 23-43).The other responses are incorrect.

Question 13

During the taking of the health history of a 78-year-old man,his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." When assessing his sensory system,which action by the nurse is most appropriate?

Accepted Answer

The nurse should ensure the validity of the sensory system testing by making certain that the patient is alert,cooperative,comfortable,and has an adequate attention span.Otherwise,the nurse may obtain misleading and invalid results.

Question 14

While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier,he tells the nurse that he is on a cruise ship and is 30 years old.The nurse knows that this finding is indicative of a(n):

Accepted Answer

A change in consciousness may be subtle.The nurse should notice any decreasing level of consciousness,disorientation,memory loss,uncooperative behavior,or even complacency in a previously combative person.The other responses are incorrect.

Question 15

The nurse is testing superficial reflexes on an adult patient.When stroking up the lateral side of the sole and across the ball of the foot,the nurse notices the plantar flexion of the toes.How should the nurse document this finding?

Accepted Answer

With the same instrument,the nurse should draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot,similar to an upside-down J.The normal response is plantar flexion of the toes and sometimes of the entire foot.A positive Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and fanning of all toes.The plantar reflex is not graded on a 0 to 4+ scale.

Question 16

In the assessment of a 1-month-old infant,the nurse notices a lack of response to noise or stimulation.The mother reports that in the last week he has been sleeping all of the time,and when he is awake all he does is cry.The nurse hears that the infant's cries are very high pitched and shrill.What should be the nurse's appropriate response to these findings?

Accepted Answer

A high-pitched,shrill cry or cat-sounding screech occurs with central nervous system damage.Lethargy,hyporeactivity,and hyperirritability,as well as the parent's report of significant changes in behavior all warrant referral.The other options are not correct responses.

Question 17

While assessing a 7-month-old infant,the nurse makes a loud noise and notices the following response: abduction and flexion of the arms and legs; fanning of the fingers,and curling of the index finger and thumb in a C position,followed by the infant bringing in the arms and legs to the body.What does the nurse know about this response?

Accepted Answer

The Moro reflex is present at birth and usually disappears at 1 to 4 months.Absence of the Moro reflex in the newborn or its persistence after 5 months of age indicates severe central nervous system injury.The other responses are incorrect.

Question 18

During the assessment of an 80-year-old patient,the nurse notices that his hands show tremors when he reaches for something and his head is always nodding.No associated rigidity is observed with movement.Which of these statements is most accurate?

Accepted Answer

Senile tremors occasionally occur.These benign tremors include an intention tremor of the hands,head nodding (as if saying yes or no),and tongue protrusion.Tremors associated with Parkinson disease include rigidity,slowness,and a weakness of voluntary movement.The other responses are incorrect.

Question 19

The nurse is testing the function of CN XI.Which statement best describes the response the nurse should expect if this nerve is intact? The patient:

Accepted Answer

The following normal findings are expected when testing the spinal accessory nerve (CN XI): The patient's sternomastoid and trapezius muscles are equal in size; the person can forcibly rotate the head both ways against resistance applied to the side of the chin with equal strength; and the patient can shrug the shoulders against resistance with equal strength on both sides.Checking the patient's ability to hear normal conversation checks the function of CN VIII.Having the patient stick out the tongue checks the function of CN XII.Testing the eyes for nystagmus or strabismus is performed to check CNs III,IV,and VI.

Question 20

Which of these tests would the nurse use to check the motor coordination of an 11-month-old infant?

Accepted Answer

To screen gross and fine motor coordination,the nurse should use the Denver II with its age-specific developmental milestones.Stereognosis tests a person's ability to recognize objects by feeling them and is not appropriate for an 11-month-old infant.Testing the deep tendon reflexes is not appropriate for checking motor coordination.Testing rapid alternating movements is appropriate for testing coordination in adults.

Quiz 23: Neurologic System