Question 1

A nurse assesses a client and notes the client's position as indicated in the illustration below:

How should the nurse document this finding?

Accepted Answer

The client is demonstrating decorticate posturing,which is seen with interruption in the corticospinal pathway.This finding is abnormal and is a sign that the client's condition has deteriorated.The physician,the charge nurse,and other health care team members should be notified immediately of this change in status.Decerebrate posturing consists of external rotation and extension of the extremities.Hyperreflexes present as increased reflex responses.Spinal cord degeneration presents frequently with pain and discomfort.

Question 2

A nurse assesses a client with a brain tumor.Which newly identified assessment findings should alert the nurse to urgently communicate with the health care provider? (Select all that apply.)

Accepted Answer

The nurse should urgently communicate changes in a client's neurologic status,including a decrease in the Glasgow Coma Scale score,abnormal flexion or extension,changes in cognition or speech,and pinpointed,dilated,and nonreactive pupils.

Question 3

A nurse assesses an older client.Which assessment findings should the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.)

Accepted Answer

Normal changes in the nervous system related to aging include recent memory loss,slower processing time,decreased sensory perception,an increased risk for infection,changes in sleep patterns,changes in perception of pain,and altered balance and/or decreased coordination.

Question 4

An emergency department nurse assesses a client who was struck in the temporal lobe with a baseball.For which clinical manifestations that are related to a temporal lobe injury should the nurse assess? (Select all that apply.)

Accepted Answer

Wernicke's area (language area)is located in the temporal lobe and enables the processing of words into coherent thought as well as the understanding of written or spoken words.The temporal lobe also is responsible for the auditory center's interpretation of sound and complicated memory patterns.Personality changes are related to frontal lobe injury.Impaired taste is associated with injury to the parietal lobe.

Question 5

A nurse delegates care for an older adult client to the unlicensed assistive personnel (UAP).Which statements should the nurse include when delegating this client's care? (Select all that apply.)

Accepted Answer

The nurse should tell the UAP to schedule activities when the client is normally awake,encourage the client to use a cane when ambulating,and remind the client to look where feet are placed when walking.The nurse should assess the client for symptoms of pain and should provide sufficient time for older adults to process information,including new teaching.These are not items the nurse can delegate.

Question 6

A nurse assesses a client with a brain tumor.The client opens his eyes when the nurse calls his name,mumbles in response to questions,and follows simple commands.How should the nurse document this client's assessment using the Glasgow Coma Scale shown below?

Accepted Answer

The client opens his eyes to speech (Eye opening: To sound = 3),mumbles in response to questions (Verbal response: Inappropriate words = 3),and follows simple commands (Motor response: Obeys commands = 6).Therefore,the client's Glasgow Coma Scale score is: 3 + 3 + 6 = 12.

Question 7

After administering a medication that stimulates the sympathetic division of the autonomic nervous system,the nurse assesses the client.For which clinical manifestations should the nurse assess? (Select all that apply.)

Accepted Answer

Stimulation of the sympathetic nervous system initiates the fight-or-flight response,increasing both the heart rate and the force of contraction.A medication that stimulates the sympathetic nervous system would also increase the client's respiratory rate,blood pressure,and level of consciousness.

Question 8

A nurse assesses a client with an injury to the medulla.Which clinical manifestations should the nurse expect to find? (Select all that apply.)

Accepted Answer

Cranial nerves IX (glossopharyngeal),X (vagus),XI (accessory),and XII (hypoglossal)emerge from the medulla,as do portions of cranial nerves VII (facial)and VIII (acoustic).Damage to these nerves causes impaired swallowing,inability to shrug shoulders,and loss of the gag reflex.The other manifestations are not associated with damage to the medulla.

Question 9

A nurse assesses the left plantar reflexes of an adult client and notes the response shown in the photograph below:

Which action should the nurse take next?

Accepted Answer

This finding indicates Babinski's sign.In clients older than 2 years of age,Babinski's sign is considered abnormal and indicates central nervous system disease.The nurse should notify the health care provider and other members of the health care team because further investigation is warranted.This finding does not relate to perfusion of the leg or to pain.This is an abnormal assessment finding and should be addressed immediately.

Question 10

A nurse is caring for a client who is prescribed a computed tomography (CT)scan with iodine-based contrast.Which actions should the nurse take to prepare the client for this procedure? (Select all that apply.)

Accepted Answer

A client who is scheduled to receive iodine-based contrast should be asked about allergies,especially allergies to iodine or shellfish.The client's kidney function should also be evaluated to determine if it is safe to administer contrast during the procedure.Finally,the nurse should ensure that an informed consent is present because all clients receiving iodine-based contrast must give consent.The CT will have no impact on the client's breath sounds or hematocrit and hemoglobin levels.Findings from these assessments will not influence the client's safety during the procedure.

Quiz 41: Assessment of the Nervous System

A nurse assesses a client and notes the client's position as indicated in the illustration below: How should the nurse document this finding?

A nurse assesses a client with a brain tumor.Which newly identified assessment findings should alert the nurse to urgently communicate with the health care provider? (Select all that apply.)

A nurse assesses an older client.Which assessment findings should the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.)

An emergency department nurse assesses a client who was struck in the temporal lobe with a baseball.For which clinical manifestations that are related to a temporal lobe injury should the nurse assess? (Select all that apply.)

A nurse delegates care for an older adult client to the unlicensed assistive personnel (UAP) .Which statements should the nurse include when delegating this client's care? (Select all that apply.)

A nurse assesses a client with a brain tumor.The client opens his eyes when the nurse calls his name,mumbles in response to questions,and follows simple commands.How should the nurse document this client's assessment using the Glasgow Coma Scale shown below?

After administering a medication that stimulates the sympathetic division of the autonomic nervous system,the nurse assesses the client.For which clinical manifestations should the nurse assess? (Select all that apply.)

A nurse assesses a client with an injury to the medulla.Which clinical manifestations should the nurse expect to find? (Select all that apply.)

A nurse assesses the left plantar reflexes of an adult client and notes the response shown in the photograph below: Which action should the nurse take next?

A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodine-based contrast.Which actions should the nurse take to prepare the client for this procedure? (Select all that apply.)