Question 1

The nurse is assessing CN III (oculomotor), CN IV (trochlear), and CN VI (abducens). Which eye movements would the nurse document as nystagmus?. Select all that apply.

Accepted Answer

Nystagmus is a type of involuntary eye movement characterized by repetitive, uncontrolled movements of the eyes that may be horizontal, vertical, or rotary in nature. Options B and C describe eye movements that are consistent with nystagmus, whereas options A, D, and E do not. Option A describes normal eye movements, option D describes convergence insufficiency, and option E describes ptosis (eyelid drooping), which is not related to eye movement.

Question 2

The nurse detects an abnormality in CN VIII (facial) during a neurological assessment. Which interventions would the nurse consider?. Select all that apply.

Accepted Answer

The answer of The nurse detects an abnormality in CN...

Question 3

The nurse assesses that a patient is able move her left arm but uses her right arm to assist. The nurse would assign the affected muscle group a strength grade of ______.

Accepted Answer

The answer of The nurse assesses that a patient is...

Question 4

The nurse recognizes which observation as a positive Babinski sign?

Accepted Answer

A positive Babinski sign is indicated by dorsiflexion of the great toe and fanning of the other toes when the sole of the foot is stimulated. Option A is testing for tactile discrimination, option B is describing a normal plantar reflex, and option C is testing for vibratory sensation.

Question 5

A patient was admitted to the emergency department after falling at work. The nurse assesses that the patient's left pupil has a slightly oval shape. What nursing action is indicated?

Accepted Answer

A slightly oval-shaped pupil can indicate a potential neurological injury or increased intracranial pressure, which requires immediate attention and notification of a physician.

Question 6

When the nurse assesses the patient's abdominal superficial reflexes, the umbilicus moves in the direction of the skin stimulated. How would the nurse document this observation?

Accepted Answer

A present (+) response indicates that the superficial reflex is present and functioning normally, which is what the nurse observed when the umbilicus moved in the direction of the stimulation. Options A, B, and C all indicate an absence or uncertainty about the reflex, which does not describe the observed response.

Question 7

The patient's vision is recorded as 20/
50. The nurse is measuring what this patient can see as compared to what a normal eye can see at _______ feet.

Accepted Answer

The answer of The patient's vision is recorded as 20/
50....

Question 8

The nurse is using the OLD CARTS mnemonic to assess a patient's chief complaint of dizziness. Which information would the nurse interpret as temporal factors?. Select all that apply.

Accepted Answer

The answer of The nurse is using the OLD CARTS...

Question 9

The nurse is about to educate a 75-year-old patient on the side effects of a newly prescribed medication. The patient is both hearing and vision impaired. What should be the nurse's primary intervention?

Accepted Answer

Ensuring the patient has their glasses and functioning hearing aids will directly address their sensory impairments, facilitating better communication and understanding during the education session.

Question 10

The nurse is preparing to administer a Mini-Mental Status Examination (MMSE) on a 75-year-old patient admitted for clinical depression. What is the nurse's primary intervention for this specific patient?

Accepted Answer

The best choice for the nurse's primary intervention is to plan for the test when the patient will not be rushed to complete it. This is because the Mini-Mental Status Examination assesses cognitive function, and rushing the patient through the test may result in inaccurate results. Additionally, it is important for the nurse to ensure the patient is comfortable and not in pain, but this should be done for all patient assessments, not just the MMSE. Similarly, repeating instructions and arranging for an uninterrupted environment are good strategies for any assessment, but they are not specific to the MMSE for a patient with clinical depression.

Quiz 20: Nursing Assessment of the Patient With Neurological Disorders

The nurse is assessing CN III (oculomotor) , CN IV (trochlear) , and CN VI (abducens) . Which eye movements would the nurse document as nystagmus?. Select all that apply.