Question 1

Which confidence shared by a female client would alter the decision to use magnetic resonance imaging (MRI) as a diagnostic modality?

Accepted Answer

Before the MRI study, the client should remove all objects containing metal. If the stomach stapling left metal implanted in the client's abdomen, it would preclude the use of the MRI.

Question 2

In assessing the cause of the decreased level of consciousness in a client in a coma, the diagnostic procedure that would provide the most accurate information is

Accepted Answer

The primary purpose of CT scanning is to detect intracranial bleeding, space-occupying lesions, cerebral edema, and shifts of brain structures, which all could help explain the loss of consciousness. The history of the accident can give clues as to the nature of the injury, but will not be specific. The physical examination cannot pinpoint bleeding, lesions, cerebral edema, or shifting in structures in the brain. The x-ray is a useful tool to look for bony abnormalities and neoplasms.

Question 3

When the nurse asks the client to raise the eyebrows and grimace or puff the cheeks, the nurse would be assessing the function of cranial nerve

Accepted Answer

CN VII controls facial expressions and symmetry of the facial features. CN VIII, the vestibulocochlear or acoustic nerve, is involved with hearing and balance. CN IX (glossopharyngeal nerve) controls swallow and gag reflexes and supplies some taste. CN X is the vagus nerve and is involved in regulation of heart rate and GI motility.

Question 4

Neurologic examination reveals that a client has intact, functioning cranial nerves (CNs) III through XII. The nurse would conclude that the client has normal function of the

Accepted Answer

CNs III through XII arise in the brain stem. Testing their function provides information about the brain stem and related pathways.

Question 5

The nurse documents the client's gait as short, accelerating steps with the client shuffling in a forward-leaning posture and having difficulty starting and stopping. The nurse would identify this type of gait as

Accepted Answer

Parkinsonian gait is short, accelerating steps; shuffling; forward-leaning posture; flexed head, hips, and knees; and difficulty starting and stopping. An ataxic gait is staggering and unsteady. A dystrophic gait is with legs far apart, weight shifting from side to side (waddling in appearance). A festinating gait is one in which the client walk on his/her toes at an accelerating pace.

Question 6

During a lumbar puncture on a client in the lateral recumbent position, the physician remarks that the opening pressure is normal. The nurse would interpret this to mean that the pressure is

Accepted Answer

The normal opening pressure with the client in the lateral recumbent position is 6 to 13 mm Hg.

Question 7

If the client has adequate proprioception, the nurse would know that the client can

Accepted Answer

Proprioception is the sense of body position.

Question 8

In assessing a client for Babinski's reflex, the nurse would

Accepted Answer

Babinski's reflex is tested by gently scraping the sole of the foot with a blunt-ended object. A normal response is plantiflexion of the toes. An abnormal response (presence of Babinski's reflex) is dorsiflexion of the great toe and, often, fanning of the other toes.

Question 9

A client had a lumbar puncture and the report came back as follows: glucose 70 mg/dl, protein 32 mg/dl, opening pressure 230 mm H₂O, cells 100. The priority action by the nurse would be to

Accepted Answer

The high opening pressure (normal 70-180 mm H₂O) and the high number of cells (normal 1-5) indicate infection in the CSF or brain, which can be life-threatening. Treatment is immediate IV antibiotics. The other two findings are normal.

Question 10

The nurse would point out to a client that the advantage of magnetic resonance spectroscopy (MRS) is that the procedure

Accepted Answer

MRS can detect abnormal amounts of chemicals or molecules that are not normally present and that are markers associated with specific neurodegenerative diseases.

Question 11

In assessing function of cranial nerves (CN), the nurse offers a client toothpaste and the client can only identify it by smell. The nurse would record that

Accepted Answer

Identifying objects by smell indicates that CN I (olfactory nerve) is intact. CN II is the optic nerve. CN IV is the trochlear nerve.

Question 12

The nurse is having a client sign the informed consent form before having an electromyography (EMG). What is the most appropriate response by the nurse when the client says "The doctor will use little needles to take samples to send to the lab."

Accepted Answer

This client does not understand the procedure of EMG, which uses small needle-like electrodes inserted into muscles to measure muscle action potentials. The client is describing a muscle biopsy. The physician needs to return and re-educate the client, who can then sign the same consent form once the client understands the procedure.

Question 13

A nurse assessing a client's neurologic function. Which assessment is specifically added for the client who is suspected to have a spinal cord injury?

Accepted Answer

All options are part of a detailed neurologic assessment. However, for the client with suspected spinal cord injury, as assessment of bowel and bladder function is needed for both location and degree of injury.

Question 14

The nurse asking a client questions that test orientation would include

Accepted Answer

Questions that test for orientation relate to person, place, and time. The other options test for judgment, calculation, and long-term memory.

Question 15

A client with a head injury has had the caloric test performed using ice-cold water. When the water was injected into the auditory canal, the client's eyes moved slowly toward the irrigated side and then quickly returned to midline. The nurse would conclude after watching this reaction that the client

Accepted Answer

If brain stem function is intact, the eyes move in a conjugate fashion slowly toward the irrigated side and then quickly move back to midline.

Question 16

The nurse would explain to a client scheduled for an electroencephalogram (EEG) that an EEG

Accepted Answer

The EEG records the electrical activity of the cerebral cortex on a moving piece of paper. It is used especially to assess seizure disorders. It is also used as a proof of death when the picture is clouded with a client's use of long-acting sedatives.

Question 17

In assessing the function of CNs III, IV, and VI, the nurse would ask the client to

Accepted Answer

CNs III, IV, and VI coordinate to control eye movements in all six cardinal directions of gaze.

Question 18

A client with a brain tumor is scheduled for a spiral CT scan. Which of these factors, if present in the client's history, would affect the nurse's preparation for the scan?

Accepted Answer

The nurse should explain that a contrast agent may be used. Because some agents are iodine-based, the nurse asks whether the client has allergies to iodine or contrast material.

Question 19

When testing comprehension in a client who is expressively aphasic, the nurse lays out a pencil, a key, and a ball and then would

Accepted Answer

Clients who are expressively aphasic cannot organize speech or language to communicate, but they can understand. The client picks up the ball when asked, so the nurse knows that the client understood the request and identified the ball and picked it up.

Question 20

A nurse working on a rehabilitation unit is assessing a new admission, a client with a stable spinal cord injury. The nurse notes that the client is unable to shrug the shoulders. This finding indicates to the nurse that the level of spinal cord injury in the client is

Accepted Answer

Shoulder elevation is controlled by the supraspinous muscle, which is innervated with nerves arising from the C4-5 area. Alterations at C8-T1 would produce an inability to spread the fingers. An alteration at L1-3 would prevent the client from raising the knees to the chest. And alterations at S1-2 would prevent the client from being able to press down with the foot.

Quiz 67: Assessment of the Neurologic System

Which confidence shared by a female client would alter the decision to use magnetic resonance imaging (MRI) as a diagnostic modality?

In assessing the cause of the decreased level of consciousness in a client in a coma, the diagnostic procedure that would provide the most accurate information is

When the nurse asks the client to raise the eyebrows and grimace or puff the cheeks, the nurse would be assessing the function of cranial nerve

Neurologic examination reveals that a client has intact, functioning cranial nerves (CNs) III through XII. The nurse would conclude that the client has normal function of the

The nurse documents the client's gait as short, accelerating steps with the client shuffling in a forward-leaning posture and having difficulty starting and stopping. The nurse would identify this type of gait as

During a lumbar puncture on a client in the lateral recumbent position, the physician remarks that the opening pressure is normal. The nurse would interpret this to mean that the pressure is

If the client has adequate proprioception, the nurse would know that the client can

In assessing a client for Babinski's reflex, the nurse would

A client had a lumbar puncture and the report came back as follows: glucose 70 mg/dl, protein 32 mg/dl, opening pressure 230 mm H₂O, cells 100. The priority action by the nurse would be to

The nurse would point out to a client that the advantage of magnetic resonance spectroscopy (MRS) is that the procedure

In assessing function of cranial nerves (CN) , the nurse offers a client toothpaste and the client can only identify it by smell. The nurse would record that

The nurse is having a client sign the informed consent form before having an electromyography (EMG) . What is the most appropriate response by the nurse when the client says "The doctor will use little needles to take samples to send to the lab."

A nurse assessing a client's neurologic function. Which assessment is specifically added for the client who is suspected to have a spinal cord injury?

The nurse asking a client questions that test orientation would include

The nurse would explain to a client scheduled for an electroencephalogram (EEG) that an EEG

In assessing the function of CNs III, IV, and VI, the nurse would ask the client to

A client with a brain tumor is scheduled for a spiral CT scan. Which of these factors, if present in the client's history, would affect the nurse's preparation for the scan?

When testing comprehension in a client who is expressively aphasic, the nurse lays out a pencil, a key, and a ball and then would

A nurse working on a rehabilitation unit is assessing a new admission, a client with a stable spinal cord injury. The nurse notes that the client is unable to shrug the shoulders. This finding indicates to the nurse that the level of spinal cord injury in the client is

Quiz 67: Assessment of the Neurologic System

Which confidence shared by a female client would alter the decision to use magnetic resonance imaging (MRI) as a diagnostic modality?

In assessing the cause of the decreased level of consciousness in a client in a coma, the diagnostic procedure that would provide the most accurate information is

When the nurse asks the client to raise the eyebrows and grimace or puff the cheeks, the nurse would be assessing the function of cranial nerve

Neurologic examination reveals that a client has intact, functioning cranial nerves (CNs) III through XII. The nurse would conclude that the client has normal function of the

The nurse documents the client's gait as short, accelerating steps with the client shuffling in a forward-leaning posture and having difficulty starting and stopping. The nurse would identify this type of gait as

During a lumbar puncture on a client in the lateral recumbent position, the physician remarks that the opening pressure is normal. The nurse would interpret this to mean that the pressure is

If the client has adequate proprioception, the nurse would know that the client can

In assessing a client for Babinski's reflex, the nurse would

A client had a lumbar puncture and the report came back as follows: glucose 70 mg/dl, protein 32 mg/dl, opening pressure 230 mm H2O, cells 100. The priority action by the nurse would be to

The nurse would point out to a client that the advantage of magnetic resonance spectroscopy (MRS) is that the procedure

In assessing function of cranial nerves (CN) , the nurse offers a client toothpaste and the client can only identify it by smell. The nurse would record that

The nurse is having a client sign the informed consent form before having an electromyography (EMG) . What is the most appropriate response by the nurse when the client says "The doctor will use little needles to take samples to send to the lab."

A nurse assessing a client's neurologic function. Which assessment is specifically added for the client who is suspected to have a spinal cord injury?

The nurse asking a client questions that test orientation would include

The nurse would explain to a client scheduled for an electroencephalogram (EEG) that an EEG

In assessing the function of CNs III, IV, and VI, the nurse would ask the client to

A client with a brain tumor is scheduled for a spiral CT scan. Which of these factors, if present in the client's history, would affect the nurse's preparation for the scan?

When testing comprehension in a client who is expressively aphasic, the nurse lays out a pencil, a key, and a ball and then would

A nurse working on a rehabilitation unit is assessing a new admission, a client with a stable spinal cord injury. The nurse notes that the client is unable to shrug the shoulders. This finding indicates to the nurse that the level of spinal cord injury in the client is

A client had a lumbar puncture and the report came back as follows: glucose 70 mg/dl, protein 32 mg/dl, opening pressure 230 mm H₂O, cells 100. The priority action by the nurse would be to