Health Assessment Chapter 25 Quiz

Questions and Answers

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?

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?

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?

Refer the client for immediate medical follow-up. Signup and view all the answers

Which aspect of neurological function should the nurse address when preparing to assess a client's cerebellar function?

Balance Signup and view all the answers

How should the nurse document brisk reflexes in a client during a neurological assessment?

3+ Signup and view all the answers

Which action would be most appropriate for the nurse when having difficulty eliciting a patellar reflex during a client's neurological assessment?

Lock the fingers together and pull against each other. Signup and view all the answers

Which test would be most appropriate for assessing motor function of a client's trigeminal nerve?

Palpate temporal and masseter muscles while client clenches the teeth. Signup and view all the answers

What assessment finding is most consistent with a client diagnosed with Bell's palsy?

Inability to wrinkle the forehead Signup and view all the answers

Which of the following would be considered a normal finding when assessing cranial nerves IX and X?

Uvula and soft palate rising bilaterally Signup and view all the answers

How will the nurse perform the assessment for graphesthesia?

The client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object. Signup and view all the answers

What does an inability to stand with the feet together during the Romberg test suggest?

Cerebellar ataxia Signup and view all the answers

Which technique is most appropriate for assessing a client's deep tendon reflexes?

Hold the reflex hammer between the thumb and index finger. Signup and view all the answers

What should the nurse do first when preparing to test a client for meningeal irritation?

Ensure there is no injury to the cervical spine. Signup and view all the answers

Which cranial nerve should the nurse assess if a client reports a decrease in the ability to smell?

CN I Signup and view all the answers

Which client is at highest risk for a cerebrovascular accident?

A 68-year-old African-American male with hypertension Signup and view all the answers

What health promotion activity should the nurse prioritize for a client to reduce her risk of stroke?

Smoking cessation Signup and view all the answers

What is the most appropriate action for the nurse when a young adult client reports a head injury but did not seek care?

Refer the client for medical assessment and possible treatment. Signup and view all the answers

What age-related neurological change should the nurse be aware of when assessing an 81-year-old client?

Tremors accompanying intentional movements Signup and view all the answers

What should the nurse further assess if a client cannot perform the heel-to-shin test properly?

Balance and coordination Signup and view all the answers

What health issue is suggested if a client bends his knees during neck flexion assessment?

Meningitis Signup and view all the answers

What finding would indicate a positive Romberg test?

The client moves her feet apart to prevent herself from falling. Signup and view all the answers

What possible cause should the nurse consider for fixed, constricted pupils bilaterally in an unresponsive client?

Recent narcotic use Signup and view all the answers

What instruction should the nurse provide to a client during the assessment of CN V (trigeminal nerve)?

Clench your teeth together tightly. Signup and view all the answers

What type of gait should the nurse document for a client who is stooped over and shuffling with a stiff posture?

Parkinsonian gait Signup and view all the answers

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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Description

Test your knowledge of health assessment concepts with this quiz focused on Chapter 25. Questions cover topics such as eye assessments and neurological injuries. Challenge your understanding of the sympathetic nervous system and cerebellar functions.