Question 1

When the nurse asks the person to walk heel-to-toe, on toes, then on heels, what function is being checked?

Accepted Answer

Walking heel-to-toe, on toes, then on heels is a test of the cerebellar function, which is responsible for coordinating movement and balance. The pons and medulla oblongata are part of the brainstem, responsible for vital functions such as breathing and heart rate. The thalamus is responsible for relaying sensory information to other parts of the brain.

Question 2

A The nurse is caring for a person scheduled for an Electromyogram (EMG). How should the nurse explain this test to the person?

Accepted Answer

An Electromyogram (EMG) measures the electrical activity of the skeletal muscles.

Question 3

When the person is supine and the head is flexed to the chest without pain, resistance, or flexion of the hips or knees, the nurse is observing which neurological sign?

Accepted Answer

Brudzinski's sign is observed when flexing the head causes involuntary flexion of the hips and knees, indicating meningeal irritation. However, the absence of pain, resistance, or flexion of the hips or knees during this maneuver suggests the absence of Brudzinski's sign, which is a normal finding.

Question 4

The nurse understands that age-related changes in the neurological system include a slower response to change in balance, decreased cerebral blood flow, and decreased metabolism. What is an example of how this would affect home care for an older adult?

Accepted Answer

The decreased response time and cerebral blood flow can lead to slower processing of information, requiring additional time for the older adult to understand and complete tasks. This may need to be taken into consideration when providing home care for the older adult.

Question 5

A person is brought to the Emergency Department by the rescue squad. The person was thrown from a vehicle. There was questionable consciousness on the way to the hospital. What neurological tests does the nurse expect to see ordered?

Accepted Answer

X-rays of the skull and spine and CT scan are the most appropriate tests to assess for any fractures, swelling or bleeding in the head and spine. MRI and PET scans are usually not ordered in the acute phase of a head injury, as they are time-consuming and may not be readily available. Myelogram is not usually done in head injury patients.

Question 6

What are abnormal posturings in adults with neurological problems? (Select all that apply.)

Accepted Answer

Abnormal posturings in adults with neurological problems include decorticate and decerebrate posturing, but not dislocate or dorsiflexion. Decorticate posturing involves the arms being flexed and the legs extended, while decerebrate posturing involves stiff extension of the arms and legs.

Question 7

What is the appearance of normal cerebral spinal fluid (CSF)?

Accepted Answer

Normal CSF is typically clear and colourless. It should not have any noticeable sediment or discoloration. A pink or yellow appearance may indicate the presence of blood or elevated bilirubin levels respectively, which could indicate a medical condition. Amber-coloured CSF may be a sign of high protein content or inflammation.

Question 8

One of the most common neurological diseases is characterised by abnormal cell firing in the brain. What does this disease cause in persons?

Accepted Answer

Abnormal cell firing in the brain is a hallmark of seizures, making option D the correct choice. Migraines can cause severe headaches, nausea and sensitivity to light (photophobia), but they don't typically involve abnormal brain cell firing. Decerebrate posturing is a type of abnormal motor response that may be seen in severe brain injuries, but it is not a disease characterized by abnormal brain cell firing.

Question 9

A person is in the hospital with suspected intracerebral haemorrhage. The nurse realises that the person will most likely have which neurological test ordered?

Accepted Answer

A CT scan is the most common diagnostic test used to confirm the presence of an intracerebral hemorrhage. EEGs are used to evaluate brain activity, lumbar punctures check the cerebrospinal fluid, and x-rays of the skull are not reliable for diagnosing intracerebral hemorrhage.

Question 10

What should the nurse ask the person to do when assessing cranial nerve XII?

Accepted Answer

Cranial nerve XII, also called the hypoglossal nerve, is responsible for controlling the movements of the tongue. Therefore, asking the person to stick out their tongue and move it from side-to-side is the appropriate way to assess this nerve.

Question 11

A person in the hospital intensive care unit is being evaluated for brain death. What neurological test helps determine brain death?

Accepted Answer

The neurological test that helps determine brain death is an electroencephalogram (EEG). The test measures the electrical activity of the brain and can determine if there is any brain activity present. If there is no brain activity, it is a sign of brain death. Other diagnostic tests such as CT and cerebral angiogram may show structural changes in the brain but cannot confirm brain death. Carotid duplex study is a test that evaluates blood flow to the brain and is not relevant to determining brain death.

Question 12

The person has lower motor neuron injuries. The nurse realises that what type of reflexes are present?

Accepted Answer

Lower motor neuron injuries usually result in decreased or absent reflexes, as the nerve impulses from the spinal cord to the muscles are disrupted. Therefore, option C is the correct choice.

Question 13

What should the nurse evaluate when assessing a person's cognitive function?

Accepted Answer

Orientation and memory are key indicators of cognitive function. The ability to recall recent and past events and to know one's location, time, and identity are important in assessing cognitive function. The other options (B, C, D) are not directly related to cognitive function assessment.

Question 14

While performing the Romberg test, the nurse asks the person to stand with the feet together and eyes closed. What must the nurse observe for the test to be considered normal?

Accepted Answer

A normal Romberg test is characterized by minimal swaying for up to 20 seconds when the person stands with feet together and eyes closed.

Question 15

When the nurse is assessing the functional health pattern of health perception-health management for a person with a neurological problem, which of the following questions is appropriate?

Accepted Answer

The question in choice A pertains to the sensory functions which could be affected in a person with neurological problems. This question is appropriate to assess health perception-health management functional health pattern in such cases. The other options do not pertain to this functional health pattern.

Question 16

How would the nurse describe Alzheimer's disease to a community group? It: (Select all of the following that apply.)

Accepted Answer

Alzheimer's disease tends to have a genetic component, thus running in families, and its incidence increases with age. It is not caused by a prion, and it typically has a long duration, not a short one.

Question 17

What does the nurse need to do when assessing a person's muscle strength and movement?

Accepted Answer

When assessing muscle strength and movement, the nurse needs to observe to see whether strength and movement are bilaterally equal and strong. This involves asking the person to perform certain movements such as flexion and extension, and comparing the strength and movement capabilities in both sides of the body.

Question 18

When testing a person to determine if tremors are present, what should the nurse assess for?

Accepted Answer

Tremors are rhythmic movements, typically in the hands or arms, but can also occur in other parts of the body. Muscle spasms, diaphoresis, and jerky movements may be indicators of other conditions, but are not necessarily indicative of tremors specifically.

Question 19

Normally, a person can differentiate between soft and sharp, and can accurately feel vibrations. What should the nurse do to assess sensory function?

Accepted Answer

To assess sensory function, the nurse should touch both sides of various parts of the person's body with a sharp and a dull object to determine the person's ability to differentiate between soft and sharp sensations.

Question 20

The nurse observes a person who has a lack of coordination, clumsy movements, and an unbalanced gait. What is this called?

Accepted Answer

These symptoms are characteristic of ataxia, which is a neurological condition that affects coordination and balance. Dysarthria refers to difficulty speaking or slurred speech, kinaesthesia refers to awareness of body movement, and flaccidity refers to a lack of muscle tone or weakness.

Quiz 40: A Person-Centred Approach to Assessing the Nervous System