Question 1

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

12

Question 2

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

Lack of coordination, clumsy movements, and an unbalanced gait are all signs of ataxia. Flaccidity refers to muscle weakness, paralysis involves the inability to move a body part or muscle group, and hemiparesis refers to weakness on one side of the body.

Question 3

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

Patients with damage to the glossopharyngeal nerve (CN IX) may have impaired swallowing abilities, which can result in difficulty eating and drinking. Therefore, assessing the patient's ability to swallow before giving them a meal tray is the most appropriate action. This will help prevent aspiration or other complications during mealtime. Option A (placing the tray on the patient's right side) and option D (assisting the patient in identifying where items are on the tray) may be appropriate actions, but they should be done after assessing the patient's ability to swallow. Option C (speaking loudly and making eye contact with the patient) is unrelated to the patient's condition and can be intrusive.

Question 4

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 (CN XII) controls movement of the tongue. If the tongue deviates markedly to one side, it suggests damage or dysfunction of the hypoglossal nerve on that side. This is also known as an abnormal hypoglossal nerve response.

Question 5

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 6

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

Accepted Answer

Cognitive function includes the ability to think, reason, remember, and understand. Evaluating orientation to time, place, and person, as well as recent and past events, is a key aspect of assessing cognitive function. The ability to smell items is a sensory function, gait is a motor function, and level of consciousness is a measure of arousal and responsiveness.

Question 7

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 reflex is stronger than normal. A score of 2+ is considered normal, while a score of 4+ would indicate hyperactive reflexes. A score of 1+ or lower would indicate weaker than normal reflexes.

Question 8

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

Applying pain by pinching the sternocleidomastoid muscle can elicit an abnormal motor response (such as decorticate or decerebrate posturing), which can provide information about the patient's neurologic status. Option B is incorrect, as an unconscious patient's pain threshold is actually lower than that of a conscious patient. Option C is partially correct, as the response to pain can also indicate brainstem function, but it is primarily used to assess motor responses. Option D is incorrect, as the site of pain application may not be the most responsive or informative for every patient.

Question 9

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? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of The nurse observes signs that a patient...

Question 10

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 11

Which techniques would the nurse use to test for graphesthesia? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of Which techniques would the nurse use to...

Question 12

An emergency department ED) nurse receives a report that an incoming patient has a Glasgow Coma Scale GCS) score of 8. Which is the most appropriate action by the nurse?

Accepted Answer

A GCS score of 8 indicates a severe neurological impairment and requires immediate assessment of the patient's airway, breathing, and circulation to ensure they are stable and intervention if necessary. Pain management, obtaining a complete history, and triage can be addressed after the patient's immediate needs have been evaluated and treated.

Question 13

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

Accepted Answer

Cranial nerve XI (Spinal Accessory) controls the movement of the trapezius and sternocleidomastoid muscles, which are responsible for shrugging the shoulders and turning the head against resistance.

Question 14

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 15

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

Accepted Answer

When assessing muscle strength and movement, it is important to observe whether strength and movement are bilaterally equal and strong. This involves asking the patient to perform various movements such as grasping, pushing, pulling, and walking. The nurse should also pay attention to any weakness or paralysis. Grade the posterior tibial pulses (A) is not related to assessing muscle strength and movement. Grade flaccidity (B) is a term used to describe the degree of muscle tone, but it is not directly related to assessing muscle strength and movement. Percussing the muscle for dullness (D) is not a recommended method for assessing muscle strength and movement.

Question 16

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 17

Which terms would a nurse use to document abnormal posturing in an adult with a neurological deficit? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

Decorticate posturing and decerebrate posturing are terms used to describe abnormal posturing in patients with neurological deficits. Circumduction refers to a circular motion of a limb and is not typically used to describe abnormal posturing. Steppage is a gait abnormality and is not typically used to describe posturing. Nystagmus refers to involuntary eye movement and is not related to posturing.

Question 18

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

Accepted Answer

The nurse should stand close to the patient during the Romberg test to prevent falls and ensure the patient's safety. A is incorrect because the patient should stand during the test. C is incorrect because the patient should close their eyes during the test. D is incorrect because a sharp object is not used in this test.

Question 19

The patient is exhibiting abnormal posturing to stimuli. Which findings would the nurse document as decerebrate posturing? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

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

Question 20

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 accurately reflects the function of the Mini-Mental Status Examination, which is to evaluate an individual's cognitive abilities such as orientation, attention, memory, language, and visuospatial skills. The other answer choices do not fully capture the purpose of the examination.

Quiz 20: Nursing Assessment of the Patient With Neurological Disorders

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

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?

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?

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?

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

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

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?

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

Which techniques would the nurse use to test for graphesthesia? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply.

An emergency department ED) nurse receives a report that an incoming patient has a Glasgow Coma Scale GCS) score of 8. Which is the most appropriate action by the nurse?

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

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?

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

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

Which terms would a nurse use to document abnormal posturing in an adult with a neurological deficit? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply.

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

The patient is exhibiting abnormal posturing to stimuli. Which findings would the nurse document as decerebrate posturing? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply.

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?