Question 1

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 2

The nurse recognizes which observation as a positive Babinski sign?

Accepted Answer

Dorsiflexion of the great toe, with fanning of the other toes, is a positive Babinski sign indicating dysfunction of the pyramidal tract in the brain or spinal cord. A, B, and C are not related to the Babinski sign.

Question 3

The nurse is assessing CN III oculomotor), CN IV trochlear), and CN VI abducens). Which eye movements would the nurse document as nystagmus? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

Nystagmus is an involuntary, rhythmic oscillation of the eyes. Horizontal jerking of the eyes (option B) and rotary movement (option C) are both indicative of nystagmus. Choices A, D, and E describe other types of eye movements or abnormalities and are not indicative of nystagmus.

Question 4

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 5

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

The answer of The nurse is about to educate a...

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 there is a normal, expected response to the stimulation of the superficial abdominal reflexes. The umbilicus moving in the direction of the skin stimulated is the expected response, indicating a normal reflex. The other answer choices suggest an absence, uncertainty, or abnormality in the reflex response, which is not the case in this scenario.

Question 7

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.

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? 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 is using the OLD CARTS...

Question 9

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 10

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

Quiz 20: Nursing Assessment of the Patient With Neurological Disorders