Podcast
Questions and Answers
What assessment finding should the nurse anticipate for a client who has a lesion of the sympathetic nervous system?
What assessment finding should the nurse anticipate for a client who has a lesion of the sympathetic nervous system?
- Nystagmus (involuntary eye movement)
- Argyll-Robertson pupils
- Bilateral dilated pupils
- Constricted pupils, unresponsive to light (correct)
Which area should be the nurse's primary focus for assessment in a client who has sustained an injury to the cerebellum?
Which area should be the nurse's primary focus for assessment in a client who has sustained an injury to the cerebellum?
- Vital signs
- Respiratory status
- Coordination (correct)
- Cardiac function
What would the nurse most likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident?
What would the nurse most likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident?
- Blurred vision
- Difficulty speaking (correct)
- Loss of tactile sensation
- Inability to hear high-pitched sounds
Which action would be most appropriate for the nurse to take when a client complains of headaches each morning that resolve after getting out of bed?
Which action would be most appropriate for the nurse to take when a client complains of headaches each morning that resolve after getting out of bed?
Which aspect of neurological function should the nurse address when preparing to assess a client's cerebellar function?
Which aspect of neurological function should the nurse address when preparing to assess a client's cerebellar function?
How should the nurse document brisk reflexes in a client during a neurological assessment?
How should the nurse document brisk reflexes in a client during a neurological assessment?
Which action would be most appropriate for the nurse when having difficulty eliciting a patellar reflex during a client's neurological assessment?
Which action would be most appropriate for the nurse when having difficulty eliciting a patellar reflex during a client's neurological assessment?
Which test would be most appropriate for assessing motor function of a client's trigeminal nerve?
Which test would be most appropriate for assessing motor function of a client's trigeminal nerve?
What assessment finding is most consistent with a client diagnosed with Bell's palsy?
What assessment finding is most consistent with a client diagnosed with Bell's palsy?
Which of the following would be considered a normal finding when assessing cranial nerves IX and X?
Which of the following would be considered a normal finding when assessing cranial nerves IX and X?
How will the nurse perform the assessment for graphesthesia?
How will the nurse perform the assessment for graphesthesia?
What does an inability to stand with the feet together during the Romberg test suggest?
What does an inability to stand with the feet together during the Romberg test suggest?
Which technique is most appropriate for assessing a client's deep tendon reflexes?
Which technique is most appropriate for assessing a client's deep tendon reflexes?
What should the nurse do first when preparing to test a client for meningeal irritation?
What should the nurse do first when preparing to test a client for meningeal irritation?
Which cranial nerve should the nurse assess if a client reports a decrease in the ability to smell?
Which cranial nerve should the nurse assess if a client reports a decrease in the ability to smell?
Which client is at highest risk for a cerebrovascular accident?
Which client is at highest risk for a cerebrovascular accident?
What health promotion activity should the nurse prioritize for a client to reduce her risk of stroke?
What health promotion activity should the nurse prioritize for a client to reduce her risk of stroke?
What is the most appropriate action for the nurse when a young adult client reports a head injury but did not seek care?
What is the most appropriate action for the nurse when a young adult client reports a head injury but did not seek care?
What age-related neurological change should the nurse be aware of when assessing an 81-year-old client?
What age-related neurological change should the nurse be aware of when assessing an 81-year-old client?
What should the nurse further assess if a client cannot perform the heel-to-shin test properly?
What should the nurse further assess if a client cannot perform the heel-to-shin test properly?
What health issue is suggested if a client bends his knees during neck flexion assessment?
What health issue is suggested if a client bends his knees during neck flexion assessment?
What finding would indicate a positive Romberg test?
What finding would indicate a positive Romberg test?
What possible cause should the nurse consider for fixed, constricted pupils bilaterally in an unresponsive client?
What possible cause should the nurse consider for fixed, constricted pupils bilaterally in an unresponsive client?
What instruction should the nurse provide to a client during the assessment of CN V (trigeminal nerve)?
What instruction should the nurse provide to a client during the assessment of CN V (trigeminal nerve)?
What type of gait should the nurse document for a client who is stooped over and shuffling with a stiff posture?
What type of gait should the nurse document for a client who is stooped over and shuffling with a stiff posture?
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Study Notes
Neurological Assessments and Reflections
- Lesions in the sympathetic nervous system typically result in constricted pupils that are unresponsive to light.
- Cerebellar injuries necessitate a primary assessment of coordination.
- Frontal lobe contusions often present with difficulty speaking.
- Morning headaches that resolve after rising may indicate the need for immediate medical follow-up.
Testing Neurological Function
- Assessing cerebellar function should focus on balance.
- Brisk reflexes in a neurological assessment are documented as a 3+ finding.
- Difficulty eliciting a patellar reflex can be assisted by having the client lock their fingers and pull against each other.
Cranial Nerve Function Tests
- The trigeminal nerve (CN V) motor function is assessed by palpating the temporal and masseter muscles while the client clenches their teeth.
- In Bell's palsy, an inability to wrinkle the forehead is a key indicator.
- Normal findings for cranial nerves IX and X include a bilaterally rising uvula and soft palate during phonation.
Sensory and Motor Function Evaluation
- Graphesthesia is tested by having the client identify numbers written in their palm with their eyes closed.
- Inability to maintain feet together during the Romberg test suggests cerebellar ataxia.
- The spinothalamic tract carries pain, temperature, and light touch sensations.
Additional Key Assessments
- Deep tendon reflexes testing involves holding the reflex hammer between the thumb and index finger.
- Ensuring no cervical spine injury is crucial before testing for meningeal irritation.
- The olfactory nerve (CN I) should be evaluated in clients reporting decreased smell.
Risk Assessment and Health Recommendations
- Clients at highest risk for cerebrovascular accidents include older individuals with hypertension, particularly African-American males.
- Smoking cessation is the top recommended health promotion activity for stroke risk reduction.
- Oral contraceptives in women with a history of smoking significantly increase stroke risk.
Miscellaneous Clinical Findings
- Post-head injury clients should be referred for medical assessment if they report significant trauma without seeking care.
- Age-related changes in the neurological system may include tremors accompanying intentional movements.
- In conducting the heel-to-shin test, difficulties indicate a need for further evaluation of balance and coordination.
Diagnostic Indicators
- Fixed, constricted pupils can indicate recent narcotic use.
- A positive Romberg test is characterized by feet apart to prevent falling.
- Documenting gait abnormalities involves specific descriptors; a stooped and shuffling gait with a stiff posture suggests a Parkinsonian gait.
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