Neurological Assessment Flashcards
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
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
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.
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
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?
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
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.
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
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
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
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.
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.
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.
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
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.
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.
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.
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.
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).
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
