ch 60 assessment neuro function Flashcards
(40 cards)
a nurse is performing a neurological assessment on a client at home. during the assessment, the nurse notices that the client has a flat AFFECT. which lobe of the brain is responsible for a person’s affect?
frontal lobe
a client scheduled for an MRI has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize what action?
removing all metal-containing objects
a gerontologic nurse planning the neurological assessment of an older adult is considering normal, age-related changes that may influence the assessment results. Of what phenomenon should the nurse be aware?
reduction in cerebral blood flow
a nurse is performing a complex neurological assessment on a client recently diagnosed with alzheimer’s disease. what question should the nurse anticipate to ask when assessing the client’s language ability?
can you write your name on this blank sheet of paper?
a nurse is assessing reflexes in a client with hyperactive reflexes. when the client’s foot is abruptly dorsiflexed, it continues to “beat” two to three times before settling into a resting position. How should the nurse document this finding?
clonus
the nurse is dong an initial assessment on a client newly admitted to the unit with a diagnosis of cerebrovascular disease. the client has difficulty copying a figure that the nurse has drawn and is diagnosed with visual receptive aphasia. what brain region is primarily involved in this client’s deficit?
parietal-occipital area
what term is used to describe the fibrous connective tissue that hugs the brain closely and extends to every fold of the brain’s surface?
pia mater
the nurse is caring for a client with an upper motor neuron lesion. what clinical manifestations should the nurse anticipate when planning the client’s neurologic assessement?
loss of voluntary control of movement
the nurse is admitting a client who is diagnosed with a lower motor neuron lesion. What entry in the client’s electronic record is most consistent with the diagnosis?
client demonstrates an absence of deep tendon reflexes
an older adult client is being discharged home. the client lives alone and as atrophy of the olfactory organs. the nurse tells the client’s family that it is essential that the client have what installed in the home?
a smoke detector
the nurse is conducting a focused neurologic assessment and is assessing the client’s gag reflex. how should the nurse best perform this aspect of the assessment?
lightly touch the client’s pharynx with a cotton swab
when assessing a 36 year old male, the nurse gently strokes the client’s right palm using a cotton applicator. As the nurse strokes the client’s palm and the nurse then checks to see if the client will being to grasp the applicator. this assessment is associated with which of the following reflexes?
pathologic
a 26 year old female client, who is breastfeeding a newborn, is due to undergo a CT scan with dye contrast. what instruction should the nurse provide to the client based on this procedure?
stop breastfeeding for the time frame given by the provider within the nuclear medicine department
what neurological assessment should the nurse perform to gauge the client’s function of cranial nerve I?
have the client identify familiar odors with the eyes closed
a client is being given a medication that stimulates the parasympathetic system. following administration of this medication, the nurse should anticipate what affect?
constricted pupils
a health care provider has prescribed a EEG test for the client. what general instructions should the nurse provide to the client? select all that apply.
-the procedure generally takes 45-60 minutes
-this procedure uses a water-soluble lubricant for electrode contact which can be easily wiped off and removed using shampoo
-please refrain from drinking coffee and any caffeinated beverages the morning prior to the procedure
a client is having a “flight or fight” response after receiving a bad disease prognosis. What affect will this have on the client’s sympathetic nervous system?
increase in the secretion of sweat
in which specific instances should the nurse assess the client’s cranial nerves? select all that apply.
-when level of consciousness is decreased
-with brain stem pathology
-in the presence of peripheral nervous system disease
a client in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows the brain regulates body temperature in which of the following areas?
hypothalamus
the nurse is planning the care of a client with Parkinson’s disease. The nurse should be aware that treatment will focus on what pathophysiologic phenomenon?
decreased availability of dopamine
a client is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this client, the nurse has the client stick out the tongue and move it back and forth, what is the nurse assessing?
function for the hypoglossal nerve
a trauma client was admitted to the ICU with a brain injury that resulted in a change in level of consciousness and altered vital signs. the client subsequently became diaphoretic and agitated. The nurse should recognize which of the following syndromes as the most plausible cause of these symptoms?
sympathetic storm
the nurse is preparing to assess a client with neurologic dysfunction. What does accurate and appropriate assessment require? select all that apply.
-understanding of the tests used to diagnose neurologic disorders
-knowledge of nursing interventions related to assessment and diagnostic testing
-knowledge of the anatomy of the nervous system
when caring for a client with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would most likely elicit a response from cranial nerve VII?
observe for facial movement symmetry, such as a smile
