Chapter 47 neruo

The nurse asks an older adult patient to count backward from 100 in increments of three. The patient is challenged with the process and often pauses but performs this accurately. What should the nurse document that the patient shows?

The nurse is providing care for multiple patients. Which patient situation is most concerning and should be reported to the registered nurse (RN) or health-care provider (HCP)?

The nurse is assisting with a patient who was injured in an accident and experienced head injury. The RN records the patient as exhibiting decorticate posturing. Which condition does the nurse associate with the RN’s finding?

The nurse is preparing a patient for neurological testing. Symptoms of the patient include severe pain in the lower back from a suspected herniated disc. Which test should the nurse anticipate will be ordered?

The nurse will be accompanying a patient to the radiology department for the performance of a computerized axial tomography (CAT) scan with contrast. The patient has pain and exhibits signs of mild agitation. What action should not be taken by the nurse?

The nurse enters the room of a patient who has recently experienced a stroke. The nurse discovers the patient lying flat and choking on saliva. What action should the nurse take first?

The nurses have been placing a bedridden patient’s feet into high-top tennis shoes even while in bed. The patient’s family asks why this is being done. How should the nurse respond?

The nurse is collecting data from a patient in the HCP’s office. Which statement by the patient indicates there may be concerns of performing some activities of daily living (ADLs)

A patient is being admitted to a long-term care facility after a recent stroke with dysarthria. What should the nurse consider in providing care?

A patient comes to the emergency room exhibiting confusion and manifestations related to dementia. Records from previous visits indicate a history of treatment for sexually transmitted infections (STIs). Which lab test should the nurse question?

The nurse is preparing to perform a Romberg test on a client. The nurse instructs the patient to stand with the feet together and eyes closed. After 20 seconds, the patient leans to one side and exhibits a swaying motion. Which conclusion can the nurse draw from these test results?

The nurse is assisting with the care of a patient admitted following a fall resulting in a head injury. Which finding is a change in level of consciousness and should be reported to the RN?

. The nurse is monitoring a patient who is 4 years of age and fell down a flight of steps. The RN asks the nurse to check for a Babinski reflex and report abnormal responses. Which response will the nurse report to the RN?

The nurse is preparing to collect data for a patient’s neurological status. What equipment should the nurse gather?

The nurse is providing care for a patient who is experiencing difficulty eating due to a neurological dysfunction. Which action by the nurse will be least helpful in promoting adequate nutritional intake for this patient?

The nurse suspects a patient is experiencing a sympathetic response. What findings support this? (Select all that apply.)

. The nurse is caring for a patient scheduled for a computed tomography (CT) scan with contrast. Which actions does the nurse include in the preprocedural preparation? (Select all that apply.)

The nurse is preparing a review of the neurological system as part of a community health presentation. Which structures does the nurse identify as being part of the diencephalon? (Select all that apply.)

While observing the neurologist complete a neurological examination, the nurse notes that a patient has an absent left patellar reflex. Which possible areas of dysfunction does the nurse consider? (Select all that apply.)

The nurse is using the FOUR tool to assess a patient’s neurological functioning. In which areas does the nurse collect data when using this tool? (Select all that apply.)