Question 1

The nurse reads that a patient's reflexes are 3+. How does the nurse interpret this score?

Accepted Answer

A reflex score of 3+ indicates that the reflexes are stronger than normal. A score of 2+ is considered normal. Scores of 4+ or 5+ indicate hyperactive reflexes, while scores of 0 or 1+ indicate weaker than normal reflexes.

Question 2

While assessing an unconscious patient's neurologic status, the nurse applies pain by pinching the sternocleidomastoid muscle. Which statement by the nurse indicates an understanding of the use of this technique?

Accepted Answer

Pinching the sternocleidomastoid muscle is a painful stimulus that can elicit abnormal motor responses such as flexion or extension. This can provide important information about the patient's neurologic status, specifically their level of brain stem function. Option B is incorrect because unconscious patients may actually have a reduced pain threshold. Option C is incorrect because response to pain primarily indicates brain stem function, not cognitive function. Option D is incorrect because the patient may respond to pain at other sites as well.

Question 3

An emergency department (ED) nurse receives a report that an incoming patient has a Glasgow Coma Scale (GCS) score of

Accepted Answer

A GCS score is used to assess a patient's level of consciousness and neurological status. A score below 8 indicates a severe impairment, which requires immediate assessment and intervention of airway, breathing, and circulation. Treating pain, obtaining a complete history, and triaging the patient can wait until after the patient's ABCs (airway, breathing, and circulation) have been assessed and stabilized.

Question 4

When bringing in the meal tray for a patient with damage to the glossopharyngeal nerve (CN IX), which action by the nurse is most appropriate?

Accepted Answer

Damage to the glossopharyngeal nerve (CN IX) can result in difficulty with swallowing and may increase the risk of aspiration. Therefore, it is important for the nurse to assess the patient's ability to swallow before leaving the meal tray with the patient. This will ensure that the patient is safe to eat and reduces the risk of complications. Placing the tray on the patient's unaffected side may be helpful, but not the most important thing to do. Speaking loudly may not be necessary, as the patient is not deaf, and assisting the patient in identifying where items are on the tray may not be necessary if the patient is visually able.

Question 5

The nurse is interviewing a patient whose wife reports, "He's really forgetting things more these days." To provide the best assessment of this complaint, what should the nurse do first?

Accepted Answer

The answer of The nurse is interviewing a patient whose...

Question 6

The patient has upper motor neuron injuries. The nurse anticipates that what type of reflex is present?

Accepted Answer

The answer of The patient has upper motor neuron injuries....

Question 7

When testing cranial nerve XI (spinal accessory), the nurse should ask the patient to perform which activity?

Accepted Answer

Testing cranial nerve XI involves asking the patient to shrug their shoulders and turn their head against resistance. This assesses the function of the spinal accessory nerve which innervates the sternocleidomastoid and trapezius muscles involved in these movements. Options B, C, and D are not related to cranial nerve XI.

Question 8

Which techniques would the nurse use to test for graphesthesia?. Select all that apply.

Accepted Answer

Graphesthesia is tested by having the patient close their eyes (B) and then tracing a letter or number on the palm of their hand (D) to see if they can identify it.

Question 9

When assessing the patient's cognitive function, the nurse would evaluate which parameter?

Accepted Answer

Assessing a patient's cognitive function involves evaluating their orientation to time, place, and person, as well as their ability to recall recent and past events. This can provide information about their memory and thought processes, which is important in determining the presence of cognitive impairment or dementia. The other options listed assess different aspects of neurological function, but are not specifically related to cognitive function.

Question 10

The nurse observes a patient who has a lack of coordination, clumsy movements, and an unbalanced gait. How would the nurse document this observation?

Accepted Answer

Ataxia refers to a lack of coordination and unsteady movements, making it the most appropriate choice for documenting the patient's symptoms. Flaccidity refers to weakness or lack of muscle tone, paralysis refers to the loss of movement, and hemiparesis refers specifically to weakness or paralysis on one side of the body, and do not fully capture the patient's symptoms.

Question 11

What precaution must the nurse take when performing the Romberg test?

Accepted Answer

The nurse should stand close to the patient while performing the Romberg test to prevent the patient from falling if they lose their balance.

Question 12

During an assessment of a patient's cranial nerves, the nurse asks the patient to stick out the tongue. The nurse observes that the tongue deviates markedly to the right side. Which condition is the patient most likely exhibiting?

Accepted Answer

The hypoglossal nerve controls movement of the tongue, and is responsible for keeping the tongue in the midline. Deviation of the tongue to one side suggests abnormality of the hypoglossal nerve on that side.

Question 13

The nurse recognizes that which assessment observation of a comatose patient has the greatest implications?

Accepted Answer

The position described in option A, where both arms are extended and adducted with the palms facing down, is indicative of decerebrate posturing. This is a sign of severe brain damage and has significant implications for the patient's neurological status and prognosis.

Question 14

Which terms would a nurse use to document abnormal posturing in an adult with a neurological deficit?. Select all that apply.

Accepted Answer

Abnormal posturing in an adult with a neurological deficit can include decorticate posturing (flexor posturing) or decerebrate posturing (extensor posturing). Circumduction and steppage refer to abnormal gait patterns, and nystagmus refers to rapid involuntary movements of the eyes.

Question 15

The nurse observes signs that a patient may be experiencing dysfunction related to the acoustic nerve (CN VIII). Which action by the nurse is most appropriate for minimizing the patient's risk for injury?. Select all that apply.

Accepted Answer

The acoustic nerve (CN VIII) is related to hearing and balance. Identifying the patient's fall risk category, assisting with sitting or toileting, and placing a "falls risk" bracelet are appropriate actions to minimize injury risk due to balance issues.

Question 16

What should the nurse include in the assessment of muscle strength and movement?

Accepted Answer

In order to assess muscle strength and movement, the nurse should observe whether strength and movement are bilaterally equal and strong. This would involve assessing each muscle group for strength and symmetry, as well as assessing movements such as range of motion and coordination. Grading the posterior tibial pulses and percussing the muscle for dullness would not be relevant to assessing muscle strength and movement. Grade flaccidity may be important to assess in some cases, but it is not specific to assessing muscle strength and movement.

Question 17

An intensive care unit (ICU) nurse is preparing to assess the level of consciousness (LOC) of a patient who experienced multiple trauma injuries and is on assisted ventilation. The nurse chooses the FOUR Score Consciousness Scale for which reason?

Accepted Answer

The FOUR Score Consciousness Scale assesses levels of consciousness without relying on verbal responses, making it appropriate for patients on assisted ventilation or those who are unable to speak.

Question 18

The nurse has just finished explaining to a patient's son the function of the Mini-Mental Status Examination (MMSE). Which statement by the patient's son indicates his understanding?

Accepted Answer

Option A correctly explains the function of the MMSE, assessing the patient's cognitive abilities such as thinking, reasoning, and decision-making. Option B implies solely determining the patient's ability to live alone, which is incorrect. Option C incorrectly assumes that passing the MMSE means that the patient's mind is entirely healthy. Option D is irrelevant to the question asked.

Question 19

The patient is exhibiting abnormal posturing to stimuli. Which findings would the nurse document as decerebrate posturing?. Select all that apply.

Accepted Answer

The answer of The patient is exhibiting abnormal posturing to...

Question 20

A patient is brought to the emergency department following a motor vehicle accident. The patient jerks away from the nurse attempting to start an IV in the right arm and says, "Bring me my book. I need to eat." When asked what happened in the accident, the patient looks frantically from nurse to nurse and says, "I have a dog." Calculate the patient's Glasgow Coma Scale score.

Accepted Answer

The answer of A patient is brought to the emergency...

Quiz 20: Nursing Assessment of the Patient With Neurological Disorders