Neurological Assessment

A patient’s uvula raises midline when she says “ahh,” and she has a positive gag reflex. The nurse has just tested which cranial nerves?

a. IX and X

b. IX and XII

c. X and XII

d. XI and XI

A patient’s uvula raises midline when she says “ahh,” and she has a positive gag reflex. The nurse has just tested which cranial nerves?

a. IX and X

b. IX and XII

c. X and XII

d. XI and XI

A

During an examination, the nurse notices that a patient is unable to stick out his tongue. Which cranial nerve is involved with the successful performance of this action?

a. I

b. V

c. XI

d. XII

D

The nurse has just completed an examination of a patient’s extraocular muscles. When documenting the findings, the nurse should document the assessment of which cranial nerves?

a. II, III, and VI

b. II, IV, and V

c. III, IV, and V

d. III, IV, and VI

D

A patient is unable to shrug her shoulders against the nurse’s resistant hands. What cranial nerve is involved in successful shoulder shrugging?

a. VII

b. IX

c. XI

d. XII

C

During an examination, a patient has just successfully completed the finger-to-nose and the rapid-alternating-movements tests and is able to run each heel down the opposite shin. The nurse will conclude that the patient’s __________ function is intact.

a. Occipital

b. Cerebral

c. Temporal

d. Cerebellar

D

The nurse should use which location for eliciting deep tendon reflexes?

A) Achilles

B) Femoral

C) Scapular

D) Abdominal

ANS: A) Achilles

Deep tendon reflexes are elicited in the biceps, triceps, brachioradialis, patella, and Achilles.

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During inspection of a patient's face, the nurse notices that the facial features are symmetric. This finding indicates that which cranial nerve is intact?

A) VII

B) IX

C) XI

D) XII

ANS: A) VII

Cranial nerve VII is responsible for facial symmetry.

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During examination, the nurse finds that a patient is unable to distinguish objects placed in

his hand. The nurse would document:

a. Stereognosis

b. Astereognosis

c. Graphesthesia

d. Agraphesthesia

B

Astereognosis is the inability to identify correctly an object placed in the hand (see Chapter 25).

The two parts of the nervous system are the:

a. Motor and sensory

b. Central and peripheral

c. Peripheral and autonomic

d. Hypothalamus and cerebral

ANS: B

The nervous system can be divided into two parts—central and peripheral. The central nervous system includes the brain and the spinal cord. The peripheral nervous system includes the 12 pairs of cranial nerves (CNs), the 31 pairs of spinal nerves, and all of their branches.

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband’s personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviours is the __________ lobe.

a. Frontal

b. Parietal

c. Occipital

d. Temporal

ANS: A

The frontal lobe has areas responsible for personality, behaviour, emotions, and intellectual function. The parietal lobe has areas responsible for sensation; the occipital lobe is responsible for visual reception; and the temporal lobe is responsible for hearing, taste, and smell.

Which statement concerning the areas of the brain is true?

a. The cerebellum is the centre for speech and emotions.

b. The hypothalamus controls body temperature and regulates sleep.

c. The basal ganglia are responsible for controlling voluntary movements.

d. Motor pathways of the spinal cord and brainstem synapse in the thalamus.

ANS: B

The hypothalamus is a vital area with many important functions: body temperature controller, sleep centre, anterior and posterior pituitary gland regulator, and coordinator of autonomic nervous system activity and emotional status. The cerebellum controls motor coordination, equilibrium, and balance. The basal ganglia control autonomic movements of the body. The motor pathways of the spinal cord synapse in various areas of the spinal cord, not in the thalamus

The area of the nervous system that is responsible for mediating reflexes is the:

a. Medulla

b. Cerebellum

c. Spinal cord

d. Cerebral cortex

ANS: C

The spinal cord is the main highway for ascending and descending fibre tracts that connect the brain to the spinal nerves; it is responsible for mediating reflexes.

While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation, which of these areas must be intact?

a. Corticospinal tract, medulla, and basal ganglia

b. Pyramidal tract, hypothalamus, and sensory cortex

c. Lateral spinothalamic tract, thalamus, and sensory cortex

d. Anterior spinothalamic tract, basal ganglia, and sensory cortex

ANS: C

The spinothalamic tract contains sensory fibres that transmit the sensations of pain, temperature, and crude or light touch. Fibres carrying pain and temperature sensations ascend the lateral spinothalamic tract, whereas the sensations of crude touch form the anterior spinothalamic tract. At the thalamus, the fibres synapse with another sensory neuron, which carries the message to the sensory cortex for full interpretation. The other options are not correct

A patient with lack of oxygen to his heart will have pain in his chest and possibly in the shoulder, arms, or jaw. Which of these statements indicates that the nurse knows the best explanation for why this occurs?

a. “A problem exists with the sensory cortex and its ability to discriminate the location.”

b. “The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing the pain.”

c. “The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere.”

d. “A lesion has developed in the dorsal root, which is preventing the sensation from being transmitted normally.”

ANS: C

The sensory cortex is arranged in a specific pattern, forming a corresponding map of the body.

Pain in the right hand is perceived at a specific spot on the map. Some organs, such as the heart, liver, and spleen, are absent from the brain map. Pain originating in these organs is referred because no felt image exists in which to have pain. Pain is felt by proxy, that is, by another body part that does have a felt image. The other responses are not correct explanations

The ability that humans have to perform very skilled movements, such as writing, is controlled by the:

a. Basal ganglia

b. Corticospinal tract

c. Spinothalamic tract

d. Extrapyramidal tract

ANS: B

Corticospinal fibres mediate voluntary movement, particularly very skilled, discrete, and purposeful movements, such as writing. The corticospinal tract, also known as the pyramidal tract, is a newer, “higher” motor system that humans have that permits very skilled and purposeful movements. The other responses are not related to skilled movements

A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty maintaining her balance. Which area of the brain that is related to these findings would concern the nurse?

a. Thalamus

b. Brainstem

c. Cerebellum

d. Extrapyramidal tract

ANS: C

The cerebellar system coordinates movement, maintains equilibrium, and helps maintain posture. The thalamus is the primary relay station where sensory pathways of the spinal cord, cerebellum, and brainstem form synapses on their way to the cerebral cortex. The brainstem consists of the midbrain, pons, and medulla and has various functions, especially concerning autonomic centres. The extrapyramidal tract maintains muscle tone for gross automatic movements, such as walking

Which of these statements about the peripheral nervous system is correct?

a. The cranial nerves enter the brain through the spinal cord.

b. Efferent fibres carry sensory input to the central nervous system through the spinal cord.

c. The peripheral nerves are inside the central nervous system and carry impulses through their motor fibres.

d. The peripheral nerves carry input to the central nervous system by afferent fibres and away from the central nervous system by efferent fibres.

ANS: D

A nerve is a bundle of fibres outside of the central nervous system. The peripheral nerves carry input to the central nervous system by their sensory afferent fibres and deliver output from the central nervous system by their efferent fibres. The other responses are not related to the peripheral nervous system

A patient has a severed spinal nerve as a result of trauma. Which statement is true in this situation?

a. Because there are 31 pairs of spinal nerves, no effect results if only one nerve is severed.

b. The dermatome served by this nerve will no longer experience any sensation.

c. The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve.

d. A severed spinal nerve will only affect motor function of the patient because spinal nerves have no sensory component.

ANS: C

A dermatome is a circumscribed skin area that is primarily supplied from one spinal cord segment through a particular spinal nerve. The dermatomes overlap, which is a form of biological insurance; that is, if one nerve is severed, then most of the sensations can be transmitted by the spinal nerve above and the spinal nerve below the severed nerve.

A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient’s deep tendon reflexes (DTRs)?

a. Reflexes will be normal.

b. Reflexes cannot be elicited.

c. All reflexes will be diminished but present.

d. Some reflexes will be present, depending on the area of injury.

ANS: A

A reflex is a defense mechanism of the nervous system. It operates below the level of conscious control and permits a quick reaction to potentially painful or damaging situations

During an assessment of an 80-year-old patient, the nurse notices the following: the patient’s inability to identify vibrations at her ankle and to identify the position of her big toe, a slower and more deliberate gait, and a slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate:

a. Cranial nerve dysfunction

b. Lesion in the cerebral cortex

c. Normal changes attributable to aging

d. Demyelination of nerves attributable to a lesion

ANS: C

Some aging adults show a slower response to requests, especially for those calling for coordination of movements. The findings listed are normal in the absence of other significant abnormal findings. The other responses are incorrect

A 70-year-old woman tells the nurse that every time she gets up in the morning or after she has been sitting, she gets “really dizzy” and feels like she is going to fall over. The nurse’s best response would be:

a. “Have you been extremely tired lately?”

b. “You probably just need to drink more liquids.”

c. “I’ll refer you for a complete neurological examination.”

d. “You need to get up slowly when you’ve been lying down or sitting.”

ANS: D

Aging is accompanied by a progressive decrease in cerebral blood flow. In some people, this decrease causes dizziness and a loss of balance with a position change. These individuals need to be taught to get up slowly. The other responses are incorrect

During the taking of the health history, a patient tells the nurse that “it feels like the room is spinning around me.” The nurse would document this finding as:

a. Vertigo

b. Syncope

c. Dizziness

d. Seizure activity

ANS: A

True vertigo is rotational spinning caused by a neurological dysfunction or a problem in the vestibular apparatus or the vestibular nuclei in the brainstem.

Syncope is the sudden loss of strength or temporary loss of consciousness.

Dizziness is a lightheaded, swimming sensation.

Seizure activity is characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances

When taking the health history on a patient with a seizure disorder, the nurse is trying to determine whether the patient has an aura. Which of these would be the best question for obtaining this information?

a. “Does your muscle tone seem tense or limp?”

b. “After the seizure, do you spend a lot of time sleeping?”

c. “Do you have any warning sign before your seizure starts?”

d. “Do you experience any color change or incontinence during the seizure?”

ANS: C

Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or motor.

The other questions will not elicit information about an aura

While obtaining a health history of a 3-month-old infant from the mother, the nurse asks about the infant’s ability to suck and grasp the mother’s finger. What is the nurse assessing?

a. Reflexes

b. Intelligence

c. Cranial nerves

d. Cerebral cortex function

ANS: A

Questions regarding reflexes include such questions as “What have you noticed about the infant’s behaviour?” “Are the infant’s sucking and swallowing seem coordinated?” and “Does the infant grasp your finger?” The other responses are incorrect.

In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what response should the nurse make?

a. “Does your family know you are drinking every day?”

b. “Does the tremor change when you drink alcohol?”

c. “We’ll do some tests to see what is causing the tremor.”

d. “You really shouldn’t drink so much alcohol; it may be causing your tremor.”

ANS: B

Senile tremor is relieved by alcohol, although this is not a recommended treatment. The nurse should assess whether the person is abusing alcohol in an effort to relieve the tremor

A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurological examination?

a. Glasgow Coma Scale

b. Neurological recheck examination

c. Screening neurological examination

d. Complete neurological examination

ANS: D

The nurse should perform a complete neurological examination on an individual who has neurological concerns (e.g., headache, weakness, loss of coordination) or who is showing signs of neurological dysfunction. The Glasgow Coma Scale is used to define a person’s level of consciousness. The neurological recheck examination is appropriate for those who are demonstrating neurological deficits. The screening neurological examination is performed on seemingly well individuals with no significant subjective findings from the health history.

During an assessment of the cranial nerves, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these cranial nerves?

a. Motor component of cranial nerve IV

b. Motor component of cranial nerve VII

c. Motor and sensory components of cranial nerve XI

d. Motor component of cranial nerve X and sensory component of cranial nerve VII

ANS: B

The findings listed reflect a dysfunction of the motor component of the facial nerve (CN VII).

The nurse is testing the function of cranial nerve XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient:

a. Demonstrates the ability to hear normal conversation

b. Sticks out the tongue midline without tremors or deviation

c. Follows an object with his or her eyes without nystagmus or strabismus

d. Moves the head and shoulders against resistance with equal strength

ANS: D

The following normal findings are expected when testing the spinal accessory nerve (cranial nerve XI): The patient’s sternomastoid and trapezius muscles are equal in size; the person can forcibly rotate the head both ways against resistance applied to the side of the chin with equal strength; and the patient can shrug the shoulders against resistance with equal strength on both sides.

Checking the patient’s ability to hear normal conversation checks the function of cranial nerve VIII.

Having the patient stick out the tongue checks the function of cranial nerve XII.

Testing the eyes for nystagmus or strabismus is performed to check cranial nerves III, IV, and VI.

During the neurological assessment of an apparently healthy 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find?

a. Firm, rigid resistance to movement

b. Mild, even resistance to movement

c. Hypotonic muscles as a result of total relaxation

d. Slight pain with some directions of movement

ANS: B

Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows a mild resistance to passive stretching. In a normal individual, the nurse would observe a mild, even resistance to movement. The other responses are not correct

When the nurse asks a 68-year-old patient to stand with his feet together, arms at his side, and his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:

a. Ataxia

b. Lack of coordination

c. Negative Homans sign

d. Positive Romberg sign

ANS: D

Abnormal findings for the Romberg test include swaying, falling, and a widening base of the feet to avoid falling. A positive Romberg sign is a loss of balance that is increased by the closing of the eyes. Ataxia is an uncoordinated or unsteady gait. Homans’ sign is used to test the legs for deep venous thrombosis

The nurse is performing an assessment on a 29-year-old woman who is at the clinic complaining of “always dropping things and falling down.” While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect?

a. Vestibular disease

b. Lesion of cranial nerve IX

c. Dysfunction of the cerebellum

d. Inability to understand directions

ANS: C

When a person tries to perform rapid, alternating movements, responses that are slow, clumsy, and sloppy are indicative of cerebellar disease. The other responses are incorrect

During the health history interview with a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: “He can’t even remember how to button his shirt.” When assessing his sensory system, which action by the nurse is most appropriate?

a. The nurse would not test the sensory system as part of the examination because the results would not be valid.

b. The nurse would perform the tests, knowing that mental status does not affect sensory ability.

c. The nurse would proceed with an explanation of each test, making certain that the wife understands.

d. Before testing, the nurse would assess the patient’s mental status and ability to follow directions.

ANS: D

The nurse should perform a complete neurological examination of patients who have neurological concerns (e.g., headache, weakness, loss of coordination) or who have shown signs of neurological dysfunction. The nurse should make certain that the patient is alert, cooperative, and comfortable and has an adequate attention span by assessing mental status first to ensure validity when testing the sensory system. Otherwise, the nurse may obtain misleading and invalid results

The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception, the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one “very sharp prick.” What would be the most accurate explanation for this?

a. The patient has hyperesthesia as a result of the aging process.

b. This response is most likely the result of the summation effect.

c. The nurse was probably not poking hard enough with the pin in the other areas.

d. The patient most likely has analgesia in some areas of arm and hyperalgesia in others.

ANS: B

At least 2 seconds should be allowed to elapse between each stimulus to avoid summation.

With summation, frequent consecutive stimuli are perceived as one strong stimulus.

The other responses are incorrect.

The nurse is performing a neurological assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect?

a. Hyperalgesia

b. Hyperesthesia

c. Peripheral neuropathy

d. Lesion of sensory cortex

ANS: C

Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism).

Peripheral neuropathy is worse at the feet and gradually improves as the examiner moves up the leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome.

The other responses are incorrect

The nurse places a key in the hand of a patient, and he identifies it as a penny. What term would the nurse use to describe this finding?

a. Extinction

b. Astereognosis

c. Graphesthesia

d. Tactile discrimination

ANS: B

Stereognosis is the person’s ability to recognize objects by feeling their forms, sizes, and weights. Astereognosis is an inability to identify objects correctly, and it occurs in sensory cortex lesions. Tactile discrimination tests fine touch. Extinction tests the person’s ability to feel sensations on both sides of the body at the same point

As part of a neurological examination, the nurse is testing the DTRs of a 30-year-old woman. When striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit a reflex. The nurse’s next response should be to:

a. Ask the patient to lock her fingers and pull

b. Complete the examination, and then test these reflexes again

c. Refer the patient to a specialist for further testing

d. Document these reflexes as 0 on a scale of 0 to 4+

ANS: A

Sometimes the reflex response fails to appear. Documenting the reflexes as absent is inappropriate this soon in the examination. The nurse should try to further encourage relaxation, varying the person’s position or increasing the strength of the blow. Reinforcement is another technique to relax the muscles and enhance the response. The person should be asked to perform an isometric exercise in a muscle group somewhat away from the one being tested. For example, to enhance a reflex in the lower part of the body, the person should be asked to lock the fingers together and pull

In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side?

a. Lack of reflexes

b. Normal reflexes

c. Diminished reflexes

d. Hyperactive reflexes

ANS: D

Hyper-reflexia is the exaggerated reflex observed when the monosynaptic reflex arc is released from the influence of higher cortical levels. This response occurs with upper motor neuron lesions (e.g., a cerebrovascular accident). The other responses are incorrect

The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices that the toes curl down and away from the shin. How should the nurse document this finding?

a. Positive Babinski sign

b. Plantar reflex abnormal

c. Plantar reflex present

d. Plantar reflex 2+ on a scale from “0 to 4+”

ANS: C

With the handle of the reflex hammer, the nurse can assess for the plantar reflex by drawing a light stroke up the lateral side of the sole of the foot and across the ball of the foot, similar to an upside-down “J.” The normal response is plantar flexion of the toes (toes curl down) and sometimes of the entire foot. A positive Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and fanning of all toes. The plantar reflex is not graded on a 0-to-4+ scale.

In the assessment of a 1-month-old infant, the nurse notices lack of response to noise or stimulation. The mother reports that in the past week he has been sleeping all the time, and when he is awake all he does is cry. The nurse hears that the infant’s cries are very high pitched and shrill. What should be the nurse’s appropriate response to these findings?

a. Refer the infant for further testing

b. Talk with the mother about eating habits

c. Do nothing; these are expected findings for an infant this age

d. Tell the mother to bring the baby back in 1 week for a recheck

ANS: A

A high-pitched, shrill cry or cat-sounding screech occurs with central nervous system damage.

Lethargy, hyporeactivity, hyperirritability, and the parent’s report of significant changes in behaviour all warrant referral. The other options are not correct responses

To assess the head control of a 4-month-old infant, the nurse lifts up the infant in a prone position while supporting his chest. The nurse looks for what normal response? The infant:

a. Raises the head and arches the back

b. Extends the arms and drops down the head

c. Flexes the knees and elbows with the back straight

d. Holds the head at 45 degrees and keeps the back straight

ANS: A

At 3 months of age, the infant raises the head and arches the back as if in a swan dive. This response is the Landau reflex, which persists until 1 years of age (see Figure 25-44). The other responses are incorrect

To test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate? Ask the child to:

a. Hop on one foot

b. Stand on his head

c. Touch his finger to his nose

d. Make “funny” faces at the nurse

ANS: A

Normally, a child can hop on one foot and can balance on one foot for approximately 5 seconds by 4 years of age and can balance on one foot for 8 to 10 seconds at 5 years of age.

Children enjoy performing these tests. Failure to hop after 5 years of age indicates incoordination of gross motor skills. Asking the child to touch his or her finger to the nose checks fine motor coordination; and asking the child to make “funny” faces tests cranial nerve VII. Asking a child to stand on his or her head is not appropriate

During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. No associated rigidity is observed with movement. Which of these statements is most accurate?

a. These findings are normal, resulting from aging.

b. These findings could be related to hyperthyroidism.

c. These findings are the result of Parkinson’s disease.

d. This patient should be evaluated for a cerebellar lesion.

ANS: A

Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson’s disease include rigidity, slowness, and a weakness of voluntary movement. The other responses are incorrect

While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and that he is 30 years of age. The nurse knows that this finding is indicative of a(n):

a. Great sense of humour

b. Uncooperative behaviour

c. Inability to understand questions

d. Decreased level of consciousness

ANS: D

A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behaviour, or even complacency in a previously combative person. The other responses are incorrect

During an assessment of a 22-year-old woman who sustained a head injury from a motor vehicle accident 4 hours earlier, the nurse notices the following changes: pupils were equal, but now the right pupil is fully dilated and nonreactive; and the left pupil is 4 mm and reacts to light. What do these findings suggest?

a. Injury to the right eye

b. Increased intracranial pressure

c. Test inaccurately performed

d. Normal response after a head injury

ANS: B

In a person with a brain injury, a sudden, unilateral, dilated, and nonreactive pupil is ominous.

Cranial nerve III runs parallel to the brainstem. When increasing intracranial pressure pushes down the brainstem (uncal herniation), it puts pressure on Cranial nerve III, causing pupil dilation.

The other responses are incorrect

A 32-year-old woman tells the nurse that she has noticed “very sudden, jerky movements” mainly in her hands and arms. She says, “They seem to come and go, primarily when I am trying to do something. I haven’t noticed them when I’m sleeping.” This description suggests:

a. Tics

b. Athetosis

c. Myoclonus

d. Chorea

ANS: D

Chorea is characterized by sudden, rapid, jerky, purposeless movements that involve the limbs, trunk, or face. Chorea occurs at irregular intervals, and the movements are all accentuated by voluntary actions. (See Table 25-4 for the descriptions of athetosis, myoclonus, and tics.)

In a person with an upper motor neuron lesion after a cerebrovascular accident, which of these physical assessment findings should the nurse expect?

a. Hyper-reflexia

b. Fasciculations

c. Loss of muscle tone and flaccidity

d. Atrophy and wasting of the muscles

ANS: A

Hyper-reflexia, diminished or absent superficial reflexes, and increased muscle tone or spasticity can be expected with upper motor neuron lesions. The other options reflect a lesion of lower motor neurons (see Table 25-6)

A 59-year-old patient has a herniated intervertebral disc. Which of the following findings should the nurse expect to see on physical assessment of this individual?

a. Hyporeflexia

b. Increased muscle tone

c. Positive Babinski sign

d. Presence of pathological reflexes

ANS: A

With a herniated intervertebral disc or lower motor neuron lesion, loss of tone, flaccidity, atrophy, fasciculations, and hyporeflexia or areflexia are demonstrated. No Babinski’s sign or pathological reflexes would be observed (see Table 25-6). The other options reflect a lesion of upper motor neurons.

A multiple sclerosis patient is unable to perform rapid alternating movements, such as rapid patting of her knees. The nurse should document this inability as:

a. Ataxia

b. Astereognosis

c. Dysdiadochokinesia

d. Loss of kinesthesia

ANS: C

Slow clumsy movements and the inability to perform rapid alternating movements occur with cerebellar disease. The condition is termed dysdiadochokinesia. Multiple sclerosis has cerebellar manifestations. Ataxia is an uncoordinated or unsteady gait. Astereognosis is the inability to identify an object by feeling it. Kinesthesia is the person’s ability to perceive passive movement of the extremities or the loss of position sense.

The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)?

a. Cerebrum

b. Cerebellum

c. Cranial nerves

d. Medulla oblongata

ANS: A

The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement. The other structures are not responsible for a person’s level of consciousness.

The nurse knows that testing kinesthesia is a test of a person’s:

a. Fine touch

b. Position sense

c. Motor coordination

d. Perception of vibration

ANS: B

Kinesthesia, or position sense, is the person’s ability to perceive passive movements of the extremities. The other options are incorrect.

A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination; he said he fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurse’s finger, then his own nose, and then the nurse’s finger again (which has been moved to a different location). The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger. The nurse should suspect which of the following?

a. Cerebral injury

b. Cerebrovascular accident

c. Acute alcohol intoxication

d. Peripheral neuropathy

ANS: C

During the finger-to-finger test, if the person has clumsy movement with overshooting the mark, either a cerebellar disorder or acute alcohol intoxication should be suspected. The person’s movements should be smooth and accurate. The other options are not correct.

The nurse is assessing the neurological status of a patient who has a late-stage brain tumour. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient’s toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as:

a. Negative Babinski sign, which is normal for adults

b. Positive Babinski sign, which is abnormal for adults

c. Clonus, which is a hyperactive response

d. Achilles reflex, which is an expected response

ANS: B

Dorsiflexion of the big toe and fanning of all toes is a positive Babinski sign, also called up-going toes. This response occurs with upper motor neuron disease of the corticospinal (or pyramidal) tract and is an abnormal finding for adults.

To encourage quick response when observing someone experiencing symptoms of a stroke, the nurse uses the mnemonic:

a. BUBBLE

b. FAST

c. PERRLA

d. PQRST

ANS: B

To promote swift recognition of the symptoms of stroke among members of the public, the Heart and Stroke Foundation of Canada developed the following mnemonic:

• Face—Is it drooping?

• Arms—Can you raise both?

• Speech—Is it slurred or jumbled?

• Time—To call 9-1-1 right away.

Act FAST because the quicker you act, the more of the person you will save

The nurse is providing an informational session on stroke at a community health centre and includes the following risk factors that should be modified to decrease risk for stroke: (Select all that apply.)

a. Obesity

b. Sedentary lifestyle

c. Cigarette smoking

d. Hypoglycemia

e. High levels of low-density lipoprotein (LDL) cholesterol

f. Normotensive

ANS: A, B, C, E

The nurse is working at a blood pressure clinic with a multicultural community. The nurse ensures to provide health education resources on stroke, especially to certain individuals who are from the following ethnocultural backgrounds and have a greater risk for stroke: (Select all that apply.)

a. Middle Eastern

b. Indigenous

c. European

d. African

e. South Asian

ANS: B, D, E

Indigenous people and people of African or South Asian descent are more likely to have high blood pressure and diabetes and are therefore at greater risk for heart disease and stroke compared with the general population. Recognizing the importance of early detection of stroke, the Heart and Stroke Foundation of Canada has translated and adapted selected health education resources into Ojibway, Oji-Cree, Punjabi, Hindi, Mandarin, and Cantonese, among other languages, to help patients from diverse populations learn about the risk factors and warning signs of a heart attack

When assessing the neurological system of a hospitalized patient during morning rounds, the nurse should include which of these during the assessment?

a. Blood pressure

b. Patient’s rating of pain on a scale of 1 to 10

c. Patient’s ability to communicate

d. Patient’s personal hygiene level

ANS: C

Assessment of a patient’s ability to communicate is part of the neurological assessment.

Blood pressure and pain rating are measurements, and personal hygiene is assessed under general appearance.

The nurse is reviewing the principles of pain. Which type of pain is caused by an abnormal processing of the pain impulse through the peripheral or central nervous system?

a. Visceral

b. Referred

c. Cutaneous

d. Neuropathic

ANS: D

Neuropathic pain implies an abnormal processing of the pain message. The other types of pain are named according to their sources.

When assessing a patient’s pain, the nurse knows that an example of visceral pain would be:

a. Hip fracture.

b. Cholecystitis.

c. Second-degree burns.

d. Pain after a leg amputation.

ANS: B

Visceral pain originates from the larger interior organs, such as the gallbladder, liver, or kidneys.

A patient has been admitted to the hospital with vertebral fractures related to osteoporosis. She is in extreme pain. This type of pain would be classified as:

a. Referred

b. Cutaneous

c. Visceral

d. Deep somatic

ANS: D

Deep somatic pain comes from such sources as the blood vessels, joints, tendons, muscles, and bone. Referred pain is felt at one site but originates from another location. Cutaneous pain is derived from the skin surface and subcutaneous tissues. Visceral pain originates from the larger, interior organs

The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti?

a. I

b. III

c. VIII

d. XI

ANS: C

The nerve impulses are conducted by the auditory portion of CN VIII to the brain

The nurse notices that a patient’s palpebral fissures are unequal. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)?

a. III

b. V

c. VII

d. VIII

ANS: C

Facial muscles are mediated by CN VII; asymmetry of palpebral fissures may be attributable to damage to CN VII (Bell’s palsy)

A patient is unable to differentiate between sharp and dull stimulations to both sides of her face. The nurse suspects:

a. Bell’s palsy.

b. Damage to the trigeminal nerve.

c. Frostbite with resultant paresthesia to the cheeks.

d. Scleroderma.

ANS: B

Facial sensations of pain or touch are mediated by cranial nerve V, which is the trigeminal nerve. Bell palsy is associated with cranial nerve VII damage. Frostbite and scleroderma are not associated with this problem.

A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to cranial nerve ______ and proceeds with the examination by ________________________.

a. XI; palpating the anterior and posterior triangles

b. XI; asking the patient to shrug her shoulders against resistance

c. XII; percussing the sternomastoid and submandibular neck muscles

d. XII; assessing for a positive Romberg sign

ANS: B

The major neck muscles are the sternomastoid and the trapezius. They are innervated by cranial nerve XI, the spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the shoulders, and extension and turning of the head

When examining a patient after a biopsy of the cervical lymph nodes, to ensure there is no

a. V; trigeminal nerve.

b. XI; spinal accessory nerve.

c. VII; facial nerve.

d. VI; abducens nerve.

ANS: B

The major neck muscles are the sternomastoid and the trapezius. They are innervated by cranial nerve XI, the spinal accessory. Injury or surgery to the neck region can cause trauma to the nerve.damage to the major neck muscles, the nurse should check the function of cranial nerve.

During ocular examinations, the nurse assesses the movement of the extraocular muscles by stimulating:

a. Cranial nerves VII and VIII.

b. The ciliary body.

c. The corneal reflex.

d. Cranial nerves III, IV, and VI.

ANS: D

Movement of the extraocular muscles is stimulated by three cranial nerves: III, IV, and VI.