Neurological Assessment Flashcards

1
Q

The nurse begins the admission assessment with the collection of priority assessment data that is immediately entered into her personal digital assistant (PDA).

The nurse begins the admission assessment with the collection of priority assessment data that is immediately entered into her personal digital assistant (PDA).

a) Sensory function.
b) Orientation.
c) Speech patterns.
d) Level of consciousness. Correct

A

Sensory function is an important component of a neurological assessment, but is not the highest priority assessment at this time.

Orientation is an important component of a neuroloIn planning care, a top priority is client safety. Assessment of the client’s level of consciousness is essential to determine the care needed to ensure client safety.gical assessment, but another assessment is of higher priority.

Speech patterns are an important component of a neurological assessment, but are not the highest priority assessment at this time.

In planning care, a top priority is client safety. Assessment of the client’s level of consciousness is essential to determine the care needed to ensure client safety.

answer: Level of Consciousness

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2
Q

Based on Ms. Davidson’s recent history of loss of consciousness and falling, what additional assessment takes priority?
a) Blood pressure and pulse.

b) Pedal pulse volume.
c) Deep tendon reflexes.
d) Two-point discrimination.

A

Both hypotension and bradycardia may cause loss of consciousness, so these vital signs should be assessed immediately.

The pedal pulse volume is unlikely to provide essential data related to the client’s recent loss of consciousness.

Altered deep tendon reflexes are of less priority upon initial assessment than other assessment data.

This assessment of sensory function is of less priority upon initial assessment than other assessment data.

Answer: Blood pressure and pulse

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3
Q

To determine if the client experienced vertigo before she lost consciousness, what question should the nurse ask Ms. Davidson? Before you passed out, did you

Feel light-headed or weak?

Experience a spinning sensation?

Notice any tingling or numbness?

Have trouble moving your arms or legs?

A

Feel light-headed or weak?
This question will not elicit information specific to vertigo.
Experience a spinning sensation?
Vertigo is defined as a spinning sensation.
Notice any tingling or numbness?
This question will elicit information related to parasthesia, an abnormal sensation.
Have trouble moving your arms or legs?
This question will not elicit information specific to vertigo.

answer: Experience a spinning sensation

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4
Q

During the client interview, the nurse observes Ms. Davidson’s speech patterns. Ms. Davidson seems to have difficulty choosing and forming some of her words. What action should the nurse take?

Fill in the conversation with the words the client is attempting to say.

Allow the client to respond and ignore her difficulty to avoid embarrassment.

Affirm the client’s difficulty and question her about when this first started.

Offer to complete the interview at a later time after the client has rested.

A

Fill in the conversation with the words the client is attempting to say.
This action does not promote the most effective client assessment.
Allow the client to respond and ignore her difficulty to avoid embarrassment.
This action does not promote the most effective client assessment.
Affirm the client’s difficulty and question her about when this first started. Correct
This action demonstrates caring and also enables the nurse to obtain a more complete history related to the onset of the client’s symptoms.
Offer to complete the interview at a later time after the client has rested.
This action prevents the nurse from obtaining needed assessment data.

answer: Affirm the client’s difficulty and question her about when this first started. Correct

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5
Q

Before continuing the interview and assessment, the nurse enters the following initial data collected into her personal digital assistant (PDA):
Ms. Davidson demonstrates difficulty speaking and she previously reported feeling weak, passing out, and falling at home. Her vital signs are currently T 97º F, BP 140/88, P 92, and R 18.

Dysphagia

Tachycardia

Syncope

Paresis

A

Dysphagia.
Dysphagia refers to difficulty swallowing, and is not the correct term to use.
Tachycardia.
Tachycardia refers to a rapid pulse rate, typically greater than 100 in an adult.
Syncope. Correct
Syncope is a sudden loss of strength or temporary loss of consciousness, which the client described as “passing out.”
Paresis.
Paresis refers to partial or incomplete paralysis.

Answer: Syncope

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6
Q

In documenting the client’s difficulty speaking, the nurse recalls that Ms. Davidson had difficulty forming some of her words and phrases. Before describing this finding on the assessment form, what additional data should the nurse consider?

a) The client’s ability to comprehend what she is being asked.
b) How many words per minute the client is able to speak.
c) If any mouth drooping is observed when the client spoke.
d) Whether the client is able to read the nurse’s lips accurately.

A

The client’s ability to comprehend what she is being asked. Correct
Aphasia should be assessed to determine if the client has lost the ability to comprehend information (receptive aphasia) or the ability to express oneself (expressive aphasia). Most commonly, the client experiences both, referred to as global aphasia.
How many words per minute the client is able to speak.
This data is not useful in describing the nature of the client’s dysphasia.
If any mouth drooping is observed when the client spoke.
The presence of facial drooping is not relevant in describing the nature of the client’s dysphasia.
Whether the client is able to read the nurse’s lips accurately.
The client’s ability to read the nurse’s lips is not relevant in assessing her aphasia.

answer: The client’s ability to comprehend what she is being asked.

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7
Q

While continuing the client interview, the nurse assesses the client’s mental status. As the interview continues, Ms. Davidson occasionally struggles to choose and form words, but seems comfortable and relaxed. The nurse provides a quiet, calm environment, allowing the client ample time to respond to the interview questions.

Ms. Davidson asks the nurse what her room number is, stating she needs to let her daughter know where she is.

Which assessment by the nurse accurately reflects the client’s statement?

Disoriented to place

Oriented to situation

Loss of recent memory.

Loss of immediate memory.

A

Disoriented to place.
The fact that the client does not know her hospital room number does not indicate that she is disoriented.
Oriented to situation. Correct
The client’s statement that she needs to notify her daughter that she is in the hospital indicates she is oriented to her situation. Lack of knowledge of her room number does not reflect disorientation or memory loss.
Loss of recent memory.
The fact that the client does not know her hospital room number does not indicate that she is experiencing recent memory loss.
Loss of immediate memory.
The fact that the client does not know her hospital room number does not indicate that she is experiencing immediate memory loss.

:answer: Oriented to situation

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8
Q

To assess Ms. Davidson’s recent memory more completely, what action should the nurse take?

Question her about how she arrived at the hospital today.

Observe her cooperation in answering interview questions.

Encourage her to reminisce about the birth of her daughter.

List 4 words and ask her to repeat them back to the nurse.

A

Question her about how she arrived at the hospital today. Correct
This action provides information related to the client’s recent memory. The nurse should ask questions with verifiable answers to ensure the client does not make up responses.
Observe her cooperation in answering interview questions.
This action provides information related to the client’s mood and thought processes.
Encourage her to reminisce about the birth of her daughter.
This action will help the nurse assess the client’s remote memory.
List 4 words and ask her to repeat them back to the nurse.
This action will help the nurse evaluate the client’s immediate memory.

answer: Question her about how she arrived at the hospital today.

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9
Q

Ms. Davidson’s memory is vague about the events after she passed out, but she states that she thinks that her neighbor called an ambulance to bring her to the hospital.

Which interview data provides the nurse with information related to the client’s judgment?

a) Repeating back a list of 4 words made the client anxious and uncomfortable.
b) The client was cooperative but vague in describing how her neighbor found her.
c) Reminiscing about the birth of her daughter caused the client to cry gently.
d) The client indicated the need to notify her daughter that she is in the hospital.

A

Repeating back a list of 4 words made the client anxious and uncomfortable.
Anxiety over the need to perform a test is not a reflection of the client’s judgment.
The client was cooperative but vague in describing how her neighbor found her.
This behavior is appropriate to the situation but is not a reflection of the client’s judgment.
Reminiscing about the birth of her daughter caused the client to cry gently.
This behavior is appropriate to the situation but is not a reflection of the client’s judgment.
The client indicated the need to notify her daughter that she is in the hospital. Correct
The client’s recognition of the need to notify her daughter that she is in the hospital is an indication of good judgment.

answer: The client indicated the need to notify her daughter that she is in the hospital.

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10
Q

After completing the interview and mental status exam, the nurse tests Ms. Davidson’s cranial nerves.

In checking Ms. Davidson’s pupillary response to light, the nurse first measures the size of the pupils. Each pupil is approximately 4 mm. What action should the nurse take in response to this finding?
Document “PERRL” on the assessment record.
Compare the shape of the client’s pupils bilaterally.
Review the medications the client received in the emergency room.
Assess the client for signs of increased intracranial pressure (ICP).

A

Document “PERRL” on the assessment record.
The nurse does not have sufficient data to use this documentation, which stands for “Pupils equal, round, and reactive to light.”
Compare the shape of the client’s pupils bilaterally. Correct
Before checking the pupillary response to light, the nurse should first observe the size and shape of the pupils, observing for symmetry. The normal pupil size is 3 to 5 mm, so the nurse should next observe and compare the shape of the pupils.
Review the medications the client received in the emergency room.
Some medications may impact the size of the pupils. The normal pupil size is 3 to 5 mm, so there is no immediate need to review the client’s medications.
Assess the client for signs of increased intracranial pressure (ICP).
Changes in pupils may reflect increased ICP. The normal pupil size is 3 to 5 mm, so there is no indication that the client is experiencing increased ICP.

answer: Compare the shape of the client’s pupils bilaterally.

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11
Q

After the nurse asks the client to close both eyes what is the next action the nurse should take?
Shine a penlight into one pupil.
Move the penlight away from the pupil.
Hold a penlight to the side of one eye.
Observe the constriction of the pupil.

A
Shine a penlight into one pupil.
Another action should be taken first.
  Move the penlight away from the pupil.
Another action should be taken first.
  Hold a penlight to the side of one eye. Correct
The nurse begins by asking the client to close both eyes. This allows the pupils to dilate. The nurse next holds the penlight to the side of the eye, so it is ready as soon as the client opens her eyes.  
  Observe the constriction of the pupil.
Another action should be taken first.

answer: Hold a penlight to the side of one eye

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12
Q

To continue the cranial nerve assessment, the nurse asks Ms. Davidson to first smile, then frown, and then show her teeth. While the client performs these tasks, what should the nurse do?
Apply light pressure over the facial nerve.
Observe for symmetric facial movement.
Gently palpate for swelling over the cheeks.
Note how quickly she completes each task.

A

Apply light pressure over the facial nerve.
This action is not useful in assessing cranial nerve VII.
Observe for symmetric facial movement. Correct
The nurse observes for symmetric movement when the client smiles, frowns, or shows her teeth. This assessment provides data related to the function of the facial nerve, cranial nerve VII.
Gently palpate for swelling over the cheeks.
This action is not useful in assessing cranial nerve VII.
Note how quickly she completes each task.
This action is not useful in assessing cranial nerve VII.

answer: Observe for symmetric facial movement.

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13
Q

The nurse tests cranial nerve XI by asking the client to shrug her shoulders. What action should the nurse perform?
Internally rotate each of the client’s shoulders.
Observe the movement of the client’s clavicles.
Apply resistance to the client’s shoulders.
Slowly elevate both of the client’s arms.

A

Internally rotate each of the client’s shoulders.
Internally rotating the shoulders is not useful in testing cranial nerve XI.
Observe the movement of the client’s clavicles.
Observing the movement of the clavicles is not useful in testing cranial nerve XI.
Apply resistance to the client’s shoulders. Correct
The nurse should test the client’s ability to shrug her shoulders against resistance with equal strength bilaterally.
Slowly elevate both of the client’s arms.
Elevation of the client’s arms is not useful in testing cranial nerve XI.

answer: Apply resistance to the client’s shoulders.

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14
Q

After completing the assessment of the cranial nerves, the nurse next assesses Ms. Davidson’s motor function.

Since Ms. Davidson is lying in bed, which action should the nurse take to observe small muscle movement and coordination?
Ask the client to touch her thumb to each finger.
Stroke the lateral sides of the sole of each foot.
Use a reflex hammer to elicit arm movement.
Assist the client to sit on the side of the bed.

A

Ask the client to touch her thumb to each finger. Correct
While the client touches her thumb to each finger, the nurse observes for smooth, coordinated movement of the small muscles.
Stroke the lateral sides of the sole of each foot.
This action is used to test for the Babinski reflex and is not useful in assessing small muscle movement.
Use a reflex hammer to elicit arm movement.
This action is useful in testing deep tendon reflexes, but is not useful in assessing small muscle movement.
Assist the client to sit on the side of the bed.
It is not necessary to assist the client to a sitting position to assess small muscle movement.

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15
Q

The nurse observes that Ms. Davidson lacks coordination when touching her thumb to the fingers on her left side and decides to further assess her upper extremity muscle strength.
To assess upper extremity muscle strength, the nurse stands facing the client and holds out both hands toward the client. The nurse asks the client to grip 2 of the nurse’s fingers with 1 hand and 2 fingers with the other hand.
15.
What instruction should the nurse provide next?

Push my fingers back, using both hands at the same time.
Squeeze my fingers with 1 hand, then the other.
Pull my fingers forward toward you, 1 hand at a time.
Squeeze my fingers with both hands at the same time.

A

Push my fingers back, using both hands at the same time.
Another action more effectively assesses the client’s muscle strength.
Squeeze my fingers with 1 hand, then the other.
Another action more effectively assesses the client’s muscle strength.
Pull my fingers forward toward you, 1 hand at a time.
This action will not allow effective evaluation of the client’s muscle strength.
Squeeze my fingers with both hands at the same time. Correct
When performing a hand grip test, the nurse asks the client to squeeze the nurse’s fingers with both hands simultaneously, so that the nurse can compare muscle strength bilaterally.

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16
Q

Ms. Davidson’s left upper extremity seems to be weaker than her right upper extremity.

What additional assessment should the nurse perform to validate the finding of unilateral upper extremity weakness?
  Perform a palmar drift test.
  Complete a Romberg test.
  Check for a placing reflex.
  Observe for decorticate posturing.
A

Perform a palmar drift test. Correct
A palmar drift test is used to assess upper extremity weakness. The client is asked to hold up both arms with the palms up and the eyes closed for 10 to 20 seconds. The weak arm will “drift” downward.
Complete a Romberg test.
A Romberg test assesses the client’s balance when standing.
Check for a placing reflex.
A placing reflex is found in infants when the infant is held upright under the arms and the infant’s hop and leg move to “place” the foot.
Observe for decorticate posturing.
Decorticate posturing, abnormal flexion, is observed when a client has a lesion of the cerebral cortex.

17
Q

After validating the finding of left-sided upper extremity weakness, the nurse next assesses Ms. Davidson’s sensory function.
17.
The nurse uses a tuning fork to evaluate what sensory function?
Pain.
Vibration.
Two point discrimination.
Passive motion.

A

Pain.
The client’s ability to sense pain is assessed by gently pricking the client with a sharp object, such as a needle, rather than a tuning fork.
Vibration. Correct
The client’s ability to sense vibration is assessed by placing a vibrating tuning fork on a bony surface.
Two point discrimination.
The client’s ability to discriminate between two points is assessed by touching the client at two distinct points and noting the client’s ability to distinguish the two separate points. A tuning fork is not used for this assessment.
Passive motion.
The client’s ability to sense passive motion is assessed by moving the client’s fingers. A tuning fork is not used for this assessment.

18
Q

Next, the nurse asks Ms. Davidson to close her eyes. The nurse places the tuning fork in the palm of Ms. Davidson’s left hand and asks her to identify what she is holding. Ms. Davidson is unable to identify the tuning fork. What action should the nurse take in response to this finding?
Hold the tuning fork on the back of her hand while she tries to identify it.
Document that the client is exhibiting left-sided astereognosis.
Place a comb in the client’s left hand and ask her to identify the object.
Ask the client to open her eyes and identify the object she is holding.

A

Hold the tuning fork on the back of her hand while she tries to identify it.
The back of the hand is not used to test for stereognosis, the ability to recognize objects by touch.
Document that the client is exhibiting left-sided astereognosis.
The nurse does not have sufficient data to support this documentation.
Place a comb in the client’s left hand and ask her to identify the object. Correct
Stereognosis, the ability to recognize objects by touch, should be assessed by placing a familiar object in the client’s hand. A tuning fork in not a familiar object to many people, so the nurse should replace the fork with a more familiar object, such as a comb.
Ask the client to open her eyes and identify the object she is holding.
Stereognosis, the ability to recognize objects by touch, cannot be assessed if the client is able to see the object.

19
Q

Ms. Davidson is able to identify a comb when it is placed in her right hand, but is unable to identify the comb when it is placed in her left hand.
The nurse continues the neurological assessment by evaluating Ms. Davidson’s deep tendon reflexes (DTRs).

The nurse begins by testing the client’s biceps reflex. With the client’s forearm resting on the nurse’s forearm and the nurse’s thumb over the biceps tendon, what action should the nurse take next to test the client’s biceps reflex?
Ask the client to contract the biceps muscle.
Strike the thumb with the reflex hammer.
Extend and externally rotate the client’s forearm.
Instruct the client to repeatedly clench her fist.

A

Ask the client to contract the biceps muscle.
Contraction of the muscle should be avoided when preparing to test DTRs.
Strike the thumb with the reflex hammer. Correct
With the client’s forearm slightly flexed and relaxed, the nurse should strike the thumb with the pointed end of the reflex hammer to elicit a response.
Extend and externally rotate the client’s forearm.
The arm should be lightly flexed and relaxed rather than extended when testing DTRs.
Instruct the client to repeatedly clench her fist.
Repeatedly clenching the fist will cause muscular contraction. This should be avoided when testing DTRs.

20
Q

The nurse observes contraction of the biceps muscle and flexion of the forearm in response to the attempt to elicit the biceps reflex. What action should the nurse take in response to this finding?
Repeat the test at the same location to confirm the finding.
Record the finding as a 4+ deep tendon biceps reflex.
Document that clonus was elicited by the reflex testing.
Explain to the client that the reflex response was normal.

A

Repeat the test at the same location to confirm the finding.
There is no need to repeat the test.
Record the finding as a 4+ deep tendon biceps reflex.
A 4+ response is a very brisk, hyperactive response.
Document that clonus was elicited by the reflex testing.
Clonus is a set of short jerking muscular contractions. This was not exhibited by the client.
Explain to the client that the reflex response was normal. Correct
The client’s response is normal and should be documented as a 2+ response.

21
Q

Shortly after completing the admission assessment, the nurse returns to the client’s room and notes a change in her condition. Ms. Davidson is slurring all her words. Further assessment reveals that Ms. Davidson is no longer able to move her left arm and leg, and, within a few minutes no longer responds to the nurse’s questions.The nurse quickly assesses the client’s level of consciousness by checking for a response to varying stimuli.
21.
What stimuli should the nurse use first to attempt to elicit a response from the client?
Pinch the client’s trapezius muscle.
Vigorously shake the client’s shoulder.
Lightly touch the client’s arm.
Call the client’s name.

A
Pinch the client's trapezius muscle.
Another action should be taken first.
  Vigorously shake the client's shoulder.
Another action should be taken first.
  Lightly touch the client's arm.
Another action should be taken first.
  Call the client's name. Correct
The nurse should begin with the least amount of stimulus and progress to the greatest amount of stimulus, observing the amount of stimulus needed to evoke a response by the client.
22
Q
To objectively assess the client's level of consciousness, the nurse uses the Glasgow Coma Scale (GCS).
22.
What data should the nurse obtain to complete the client's GCS rating? (Select all that apply.)
  Verbal response.
  Pupillary response.
  Eye opening response.
  Babinski reflex.
  Motor response.
A

Verbal response. Correct
Best verbal response is assessed using the GCS and is based on a 5 point scale ranging from none to oriented.
Pupillary response.
The pupillary response to light is an important neurologic assessment, but is not included in the GCS rating.
Eye opening response. Correct
Best eye opening response is assessed using the GCS and is based on a 4 point scale ranging from none to opens eyes spontaneously.
Babinski reflex.
The Babinski reflex is not a component of the GCS rating.
Motor response. Correct
Best motor response is assessed using the GCS and is based on a 6 point scale ranging from none to obeys commands for movements.

23
Q

Ms. Davidson’s daughter Sylvia has arrived and the nurse explains that her mother’s condition has worsened. Sylvia cries, and tells the nurse that her mother had often told her that she had lived a full, long life, and did not want any extraordinary measures in the event of a serious illness.The nurse assesses Ms. Davidson’s end of life wishes.
23.
In assessing the client’s end of life wishes, the nurse remembers that Ms. Davidson’s husband is deceased. It is most important for the nurse to communicate with which person? The client’s
daughter Sylvia, her oldest child.
designated power of attorney for health care.
physician, with whom she has discussed her wishes.
priest, since she is a member of a Catholic parish.

A

daughter Sylvia, her oldest child.
While the wishes of a client’s children are important, another person is more important in assessing a client’s end of life wishes.
designated power of attorney for health care. Correct
The person designated as a client’s power of attorney for health care has been designated by the client to make health care decisions for the client if the client is unable to do so.
physician, with whom she has discussed her wishes.
The client’s physician is an important member of the health care team, but is not the most important person to consult regarding a client’s end of life wishes.
priest, since she is a member of a Catholic parish.
A client’s spiritual leader, such as a rabbi, priest, or pastor, may be contacted at the request of the client or family, but is not the most important person to consult when assessing a client’s end of life wishes.

24
Q

The nurse learns that Ms. Davidson designated her daughter Sylvia as her power of attorney. Sylvia tells the nurse that her mother was very clear in her wishes and does not wish to have external feeding, ventilation, or resuscitation implemented under any circumstances.

To confirm the verbal information regarding Ms. Davidson’s end of life wishes, the nurse plans to review the client’s living will.
24.
What additional information related to end of life wishes is most important for the nurse to assess?
Wishes of other children.
If the client prepared a will.
Desired funeral home.
Organ donor status.

A

Wishes of other children.
While the wishes of family members are important to assess, the client’s wishes as designated in the living will are more important. Therefore, other information is of higher priority.
If the client prepared a will.
This information is unlikely to impact nursing care, and is not of high priority for the nurse to ascertain.
Desired funeral home.
It is important to obtain information regarding the client’s desired mortuary, but other information is of higher priority.
Organ donor status. Correct
It is essential for the nurse to assess the client’s wishes regarding organ donation so that any necessary arrangements to preserve organs can be made prior to the client’s death.

25
Q

The nurse may facilitate time and space for which action(s) commonly associated with spiritual end of life care related to Ms. Davidson’s Catholic beliefs. (Select all that apply.)
The presence of a Rabbi.
Last rites or anointing of the sick.
Position the hospital bed to face the East.
Prayer of the Rosary.
The presence of a Shaman.

A

The presence of a Rabbi.
A Rabbi is the spiritual leader for the Jewish faith, not the Catholic faith.
Last rites or anointing of the sick. Correct
The practice of last rites, which includes a combination of prayer and anointing with oils by a Catholic priest, is a common end of life practice associated with the Catholic faith.
Position the hospital bed to face the East.
A request to face the East or Mecca is typically associated with the Islamic faith.
Prayer of the Rosary. Correct
The Rosary is a traditional Catholic devotion involving meditation and prayer and is often included by clients, family, visitors and clergy in end of life care.
The presence of a Shaman.
A Shaman is typically associated with Native American healing practices, not the Catholic faith.