Health Assessment Neurological System Review For Quiz

CN I

olfactory, sensory; smell reception and interpretation

Have patient smell same substance out of one nostril at a time

CN II

optic, sensory; visual acuity and visual fields

Use Snellen chart and ophthalmoscope

CN III

oculomotor, motor; raise eyelids, most extraocular movements

assessed together for eye movement controlled by muscles

CN IV

trochlear, motor; downward, inward eye movement

CN V

Trigeminal,Both; jaw opening and clenching, chewing and mastication

CN VI

Abducens, Motor; lateral eye movement

CN VII

Facial, Both

Motor: movement of facial expression muscle except jaw, close eyes, labial speech sounds

Sensory: taste on the anterior two thirds of tongue, sensation to pharynx

Parasympathetic: secretion of saliva and tears

CN VIII

Acoustic (vestibulocochlear), Sensory; hearing and equilibrium

CN IX

glossopharyngeal, Both

Motor: voluntary muscle for swallowing and phonation

Sensory: sensation of nasopharnyx, gag reflex, taste on the posterior one third of tongue

Parasympathetic: secretion of salivary glands, carotid reflex

CN X

vagus, both

Motor: voluntary muscles of phonation and swallowing

Sensory: sensation behind ear and part of external ear canal

Parasympathetic: secretion of digestive enzymes; peristalsis; carotid reflex; involuntary action of heart, lungs, and digestive tract

CN XI

spinal accessory, motor; turn head, shrug shoulders, some actions for phonation

CN XII

hypoglossal, motor;tongue movement for speech sound articulation and swallowing

Kernig's sign:

flexing one leg at hip and knee, then extending knee. No pain indicates negative kernig's sign. If inflammation of meninges, patient reports pain along vertebral column when leg is extended.

Brudzinski's sign

test when patient is supine. Patient's neck is flexed: reports no pain or resistance to neck flexion. Positive Brudzinski's sign is the patient is passively flexing hip and knee in response to head flexion and reports pain along vertebral column

Multiple Sclerosis

Progressive demylination of nerve fibers of brain and spinal cord. Autoimmune disorder initiated by virus attacks on myelin at various sites of CNS.

Meningitis

inflammation of meninges that surround the brain and spinal cord

Bacteral is most common

Encephalitis

inflammation of brain tissue and meninges caused by bacteria, viruses, fungi, and parasites.

Viral is most common

Spinal Cord Injury

Traumatic disruption of spinal cord from car accidents, sports injuries, violent impacts

Craniocerebral Injury

injury to scalp, skull, brain sufficient to alter normal function

Parkinson's Disease

develops slowly as brain's dopamine producing neurons degenerate

CVA

cerebrovascular vessels become occluded by thrombus or embolus or when intracranial hemorrhage occurs and brain tissue becomes ischemic

Alzheimer's Disease

incurable, degenerative disease neurologic disorder, begins with decline in memory. Patients with a history of small strokes have a tendency to develop this. Stroke prevention measures may reduce risk of developing this disease

Trigeminal Neuralgia

intense paroxysmal pain; ethiology is unknown but trauma to face or head or infection of teeth or jaw are contributing factors

Bell's Palsey

acute unilateral paralysis of facial nerve

Myasthenia Gravis

Neuromuscular disease with abnormal weakness of voluntary muscles, improves with rest and anticholinesterase drugs

3 Types: Ocular, Bulbar, and generalized

Guillain-barre Syndrome

Widespread demyelinization of nerves of peripheral nervous system, auto-immune response to viral infection. May have gastrointestinal or respiratory viral infection weeks before onset. 80-90% recover with few or no residual deficits, but may die from respiratory depression.

Older Adults

tests for balance and gait are often assessed to identify those at risk for falls

Infants

sensation and cranial nerves are assessed by observation

Children

motor development is compared with standardized tables of normal age and sequences of motor development

Romberg test

test for balance

The nurse is preparing to assess a patient's peripheral nervous sensory function. Which assessment test would the nurse use?

a Light touch sensation

b Two-point discrimination

c Romberg

d Rinne

a Light Touch Sensation

Sensory neurologic testing cannot realistically be performed with children until they are:

a at least 6 months old.

b toddlers.

c kindergarten age.

d middle school age.

c kindergarten age.

Which statement regarding variations in neurologic functioning is true?

a African-American adults have an enhanced reflex response.

b American Indian children tend to develop early motor skills more rapidly than other children.

c Asians have a greater sensation than do whites.

d The function of the neurologic system is consistent across racial lines.

d The function of the neurologic system is consistent across racial lines.

The nurse assesses an active reflex response. Which score should be documented?

a 1+

b 2+

c 3+

d 4+

b 2+ (expected response)

The nurse is assessing an older adult's neurologic status. The nurse should be aware that the neurologic responses of older adults:

a should be the same as those of younger adults.

b may be slower than those of younger adults.

c are present but difficult to evaluate.

d are enhanced as a result of irritability.

b may be slower than those of younger adults.

The nurse is assessing the olfactory nerve. Which instructions should the nurse give to the patient before assessment?

a "Lie down on your back."

b "Close your eyes."

c "Close both of your nostrils."

d "Breathe through your mouth."

b "Close your eyes."

The nurse notices that a patient is able to understand what is said but has trouble formulating a response. The nurse suspects:

a Parkinson disease.

b Guillain-Barré syndrome.

c receptive aphasia.

d expressive aphasia.

d expressive aphasia.

The nurse notes that the patient is able to touch each finger to his thumb in rapid sequence. This finding indicates that the patient:

a has intact trochlear and abducens cranial nerves.

b has appropriate cerebellar function.

c has an intact spinal accessory nerve.

d has appropriate kinesthetic sensation.

b has appropriate cerebellar function.

A 52-year-old obese male who smokes and has diabetes has risk factors for:

a seizures.

b Guillain-Barré syndrome.

c multiple sclerosis.

d cerebrovascular accident.

d cerebrovascular accident.

The nurse is assessing a patient's neurologic status. What assessment should the nurse perform? (Select all that apply.)

a Romberg test

b Glasgow Coma Scale

c Tonic neck

d Corneal reflex

e Mini-Mental State Exam

f Recall test

b Glasgow Coma Scale

d Corneal reflex

e Mini-Mental State Exam

f Recall test

Rinne

screening test for hearing

Tonic neck

is used with infants to check infantile reflexes.

Which findings are considered normal on assessment of the oculomotor, trochlear, and abducens cranial nerves?

Select all that apply.

a Palpebral fissures are symmetric.

b Both pupils constrict with accommodation.

c Bilateral peripheral vision is intact.

d Optic disc has well-defined margins on ophthalmologic examination.

e Both pupils constrict in response to light directly and consensually.

a Palpebral fissures are symmetric.

b Both pupils constrict with accommodation.

e Both pupils constrict in response to light directly and consensually.

Which facial movements are expected on assessment of the facial nerve (CN VII)?

Select all that apply.

a Smile

b Show teeth

c Stick out tongue

d Puff out cheeks

e Raise eyebrows

a Smile

b Show teeth

d Puff out cheeks

e Raise eyebrows

Which findings are considered normal on assessment of the acoustic nerve (CN VII)?

Select all that apply.

a Sound from tuning fork lateralizes to the right ear.

b Sound from tuning fork is heard equally in both ears.

c Air conduction of sound is greater than bone conduction of sound.

d Bone conduction of sound is greater than air conduction of sound.

e Individual is able to correctly repeat words whispered in both ears.

b Sound from tuning fork is heard equally in both ears.

c Air conduction of sound is greater than bone conduction of sound.

e Individual is able to correctly repeat words whispered in both ears.

The patient is found to have active, expected deep tendon reflexes. Which score represents the expected deep tendon reflex finding?

0

1+

2+

3+

2+

Which finding is considered normal on evaluation of the cremasteric reflex?

Testicle and scrotum rise on the unstroked side.

Testicle and scrotum rise on the stroked side.

Both testicles and scrotum remain stationary when stroked on either side.

Both testicles and scrotum tense when stroked on either side.

Testicle and scrotum rise on the stroked side.

Which movement of the foot is expected when the Achilles reflex is evaluated?

Supination of the foot

Pronation of the foot

Plantar flexion of the foot

Plantar extension of the foot

Plantar flexion of the foot

During the heel-to-shin neurologic test, which findings suggest intact proprioception?

Select all that apply.

a Absence of tremors with movement

b Presence of occasional tremors with movement

c Ability to move heel along shin quickly

d Ability to maintain contact of heel with shin

e Ability to move heel along shin in straight path

a Absence of tremors with movement

d Ability to maintain contact of heel with shin

e Ability to move heel along shin in straight path

Which finding suggests normal balance while the patient is hopping on one foot with eyes open?

Ability to hop for 60 seconds with good balance

Ability to hop for 45 seconds with good balance

Ability to hop for 30 seconds with good balance

Ability to hop for 5 seconds with good balance

Ability to hop for 5 seconds with good balance

When a patient's normal gait is being evaluated, which findings are expected and considered normal?

Select all that apply.

Gait is smooth and rhythmic.

Arm swing is smooth and symmetric.

Trunk posture sways with gait.

Trunk posture stays stationary.

Arms stay stationary at sides.

Gait is smooth and rhythmic.

Arm swing is smooth and symmetric.

Trunk posture sways with gait.

The nurse uses the rounded portion of a tongue blade on the toe to test a patient's sense of superficial pain. Which patient response indicates a normal finding?

Select all that apply.

"I can feel the sensation more on the right foot than on the left."

"That feels dull and is not painful."

"That feels sharp and is painful."

"I can feel the sensation on the heel of my foot."

"That feels sharp and is painful."

The patient has an intact sense of graphesthesia as evidenced by which finding?

Can identify where touched on arm

Can identify figure drawn on palm

Can identify object placed in palm

Can identify being touched on the arm in one point or two points

Can identify figure drawn on palm

During the neurologic test for vibratory sensation, which normal finding is expected?

Ability to feel a vibration in the muscle

Ability to feel a vibration on the skin

Ability to feel a vibration in the joint

Ability to feel a vibration radiating through the limb

Ability to feel a vibration in the joint

During a neurologic examination of a 3-month-old infant, which findings are related to the presence of primitive reflexes?

Select all that apply.

Withdraws all limbs from pain stimulus

Alternates flexion and extension of legs

Grasps object strongly when placed in palm

Moves head and opens mouth to external mouth stimulation when hungry

Turns eyes in direction of rotation and in opposite direction when rotation stops

Alternates flexion and extension of legs

Grasps object strongly when placed in palm

Moves head and opens mouth to external mouth stimulation when hungry

Which statement describes the gait of an older child as compared with the gait of a newly walking child?

Feet far apart

Feet close together

Shuffling of feet

Shorter steps

Feet close together

Which cranial nerve senses may be diminished in the older adult?

Select all that apply.

Sense of sight

Sense of touch

Sense of smell

Sense of hearing

Sense of sight, smell, hearing

Multiple Sclerosis Abnormal Finding

Hyperactive deep tendon reflexes

Guillain-Barré syndrome Abnormal Finding

Hypoactive deep tendon reflexes

Bell palsy Abnormal Finding

Ptosis

Meningitis Abnormal Finding

Nuchal rigidity

The pregnant patient is in her third trimester and has been diagnosed with intrapartum maternal lumbosacral plexopathy as evidenced by which subjective symptom?

Unilateral foot drop

Uterine cramping

Abdominal gas

Pain radiating from buttock to the leg

Pain radiating from buttock to the leg

Which objective data suggest a child has cerebral palsy?

Select all that apply.

Cognitive impairments

Exposed meningeal sac

Persistent primitive reflexes

Exaggerated deep tendon reflexes

Rapidly increasing head circumference

Cognitive impairments

Persistent primitive reflexes

Exaggerated deep tendon reflexes

The older adult is newly diagnosed with Parkinson disease and demonstrates which objective signs?

Select all that apply.

Tremors

Numbness of legs

Muscular rigidity

Muscle soreness

Short, shuffling steps

Tremors

Muscular rigidity

Short, shuffling steps

The adult patient has had a stroke as evidenced by which objective signs?

Aphasia

Numbness of left leg

Altered level of consciousness

Trouble seeing in both eyes

Difficulty managing secretions

Aphasia

Altered LOC

Difficulty managing secretions

Cerebral palsy Pediatric Abnormal Finding

Persistent primitive reflexes

Spina Bifida Pediatric Abnormal Finding

Loss of bowel control

Shaken baby syndrome Pediatric Abnormal Finding

Retinal hemorrhages