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?

Accepted Answer

The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the client read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to check function of the oculomotor nerve.

Question 2

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

Accepted Answer

For a lumbar puncture, the client lies in the lateral recumbent position. The procedure does not usually require a sedative, is done in the client room, and has no risk for aspiration.

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?

Accepted Answer

Seizure disorders are usually studied using EEG testing. Evoked potential is used for diagnosing problems with the visual or auditory systems. Cerebral angiography is used to diagnose vascular problems. EMG is used to evaluate electrical innervation to skeletal muscle.

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?

Accepted Answer

Level of consciousness (LOC) is the most sensitive indicator of changes in neurological status.

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?

Accepted Answer

The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex; a client with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a client is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve.

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?

Accepted Answer

Because functions of the cerebellum include coordination and balance, the client with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability.

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?

Accepted Answer

Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor neuron lesions.

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?

Accepted Answer

After a head injury, the client may be experiencing intracranial bleeding and increased intracranial pressure, which could lead to herniation of the brain with lumbar puncture. The other orders are appropriate.

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?

Accepted Answer

Although changes in appetite are normal with aging, a 9.1 kg weight loss requires further investigation. Orthostatic drops in blood pressure, changes in sleep patterns, and slowing of reflexes are normal changes in aging.

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?

Accepted Answer

A positive Romberg test indicates that the client has difficulty maintaining balance with the eyes closed. The Romberg does not test for autonomic dysreflexia, thermoregulation, or hyper-reflexia.

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?

Accepted Answer

Inhibition of the fight or flight response leads to decreased heart rate. Dry mouth, constipation, and urinary retention are associated with peripheral nervous system blockade.

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?

Accepted Answer

The protein level is high. The pH, WBCs, and glucose values are normal.

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?

Accepted Answer

When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate.

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?

Accepted Answer

Since a catheter is inserted into an artery (such as the femoral artery) during cerebral angiography, the nurse should assess for bleeding after this procedure. The other nursing assessments are not necessary after angiography.

Question 15

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

Accepted Answer

Vibration sense is testing by touching the client with a vibrating tuning fork. The other equipment is needed for testing of pain sensation, reflexes, and two-point discrimination.

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?

Accepted Answer

Expressive speech is controlled by Broca's area in the frontal lobe. The temporal lobe contains Wernicke's area, which is responsible for receptive speech. The cerebellum and brain stem do not affect higher cognitive functions such as speech.

Question 17

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

Accepted Answer

The cerebellum is responsible for coordination and is assessed by looking at the client's gait and the finger-to-nose test. The other assessments will be used for other parts of the neurological assessment.

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?

Accepted Answer

When admitting a client who is likely to be a poor historian, the nurse should obtain health history information from others who have knowledge about the client's health. Waiting until the client is oriented or obtaining only physiological data will result in incomplete assessment data; this could adversely affect decision-making about treatment. Asking leading questions may result in inaccurate or incomplete information.

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?

Accepted Answer

The posterior temporal lobe integrates the visual and auditory input for language comprehension. Reasoning and problem solving are functions of the anterior frontal lobe. Sensation on the left side of the body is located in the right postcentral gyrus. Voluntary movement on the right side is controlled in the left precentral gyrus.

Question 20

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

Accepted Answer

Vital centres that control respiration are located in the medulla, and these are the priority assessments because changes in respiratory function may be life threatening. The other information also will be collected by the nurse, but it is not as urgent.

Quiz 58: Nursing Assessment Nervous System