Neuromuscular Assessment

Created by amandaeason 

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Criteria for Grading Muscle Strength

0 - No movement
1 - Twitch
2 - complete range of motion with gravity removed (lateral leg slide)
3 - complete range of motion with gravity
4 - complete range of motion against gravity with some resistance
5 - complete range of motion against gravity with full resistance

Grading Scale for Deep Tendon Refelex

0 - No response
1+ - Sluggish or diminished
2+ - Active; normal response
3+ - Brisk
4+ - Hyperactive

The nurse is performing a neurological assessment on a clinet and elicits a positive Romberg's sign. The nurse makes this determination based on which observation?

A) An involuntary rhythmic, rapid, twitching of the eyeballs

B) A dorsiflexion of the ankle and great toe with fanning of the other toes

C) A significant sway when the client stands erect with feet together, amrs at the side, and the eyes closed

D) A lack of normal sense of position when the client is unable to return extended fingers to a point of reference

C) A significant sway when the client stands erect with feet together, amrs at the side, and the eyes closed

What section of the brain is responsible for reasoning and personality?

Frontal

A patient with a positive Romberg's test may have problems in what part of the brain?

Cerebellum - responsible for balance/coordination

A patient enters the ER with left-sided weakness. It is suspected that patient has suffered a stroke. What side of the brain has the TIA occured on?

Right

What part of the brain controls breathing and heart rate?

brainstem

Nerve tracks that carry impulses to the brain from the organs are called what?

afferent

Nerve tracks that carry nerve impulses from the brain to the organs are called what?

efferent

Level of Consciousness Rating:

Alert - eyes open
Lethargic - sleepy, easily aroused, still able to answer questions
Obtunded - needs gentle arousing (light shake)
Stuporous - patient requires painful stimul to be aroused
Coma - no response

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse implements which physical assessment technique to assess for muscle weakness in the eye?

A) Tests the corneal reflexes
B) Test the six cardnial positions of gaze
C) test visual acuity using a Snellen eye chart
D) Test sensory function by asking the client to close eyes and then lightly touching the forehead, cheeks and chin

B) Test the six cardnial positions of gaze

The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain?

A) Sternal rub
B) Nail bed pressure
C) Pressure on the orbital rim
D) Squeezing of the sternocleidomastoid muscle

A) Sternal rub

During an assessment of a patient with tremors the nurse notices that as the patient reaches for a glass of water his tremors subside. The nurse would suspect this patient may be showing signs of what condition?

Parkinsons

When assessing the motor function of a patient using the Glasgow coma scale, the nurse notes the patient's hands and feets are turned inward. The nurse notes this a 3 which is called what?

Abnormal flexion - decordian

The nurse understands that the lowest possible score the patient can receive on the Glasgow Coma scale is what?

3

The three areas being tested on the Glasgow Coma Scale are what?

Eye opening, Motor response, Verbal Response

A nurse assigned to the post-op care of a patient who has just had a lumbar puncture test understands that she must closely monitor the client for was complication?

leakage of the cerbral spinal fluid

During a neuro assessment the nurse notes the patient to be arousable but drowsy, the patient can state their name but not where they are. How would the nurse document this finding?

Lethargic and disoriented

When testing a patient's reflexes the nurse notes the right patella reflex as being brisk. How would this be documented?

3

Which cranial nerve is being tested when a patient is asked to read the Snellen chart?

2 - Optic

What are the five verbal responses on the Glasgow Coma Scale?

Oriented
Confused
Inappropriate Words
Incomprehensible; moaning
No Response

What cranial nerve is being tested when the nurse places their hand on the clients claw and asks the client to clench their teeth?

5 - Trigeminal

What is the appropriate amount of time for the nurse to apply stimuli when using the sternal rub?

20 - 30 seconds

Which statement about the Glasgow Coma Scale is correct?

A) It is a thorough neurologic assessment tool
response
B) It establishes a baseline for eye opening and motor and verbal response
C) It establishes cognitive function
D) A score of 15 indicates serious neurologic impairment with poor prognosis

B) It establishes a baseline for eye opening and motor and verbal response

How does PTH respond when calcium levels are low?

- Stimulate osteoclast activity in bone
- Stimulate kidney to reduce excretion of calcium
- Stimulate GI to increase calcium absorption

Which hormone is responsible for bone length?

Growth hormone

A patient with bursitis asks the nurse what the does bursa do. How does the nurse respond?

Relieve friction between moving parts

What cranial nerve(s) are being assessed when the nurse is checking the six cardinal gazes?

3 - Oculomotor
4 - Trochlear
6 - Abducens

When grading muscle stregth, grade 1 means what?

Flicker

A patient is scheduled for an arthrocentis procedure. How should the nurse explain what is involved in this procedure?

incision or puncture of joint capsule

What cranial nerve is being assessed when a patient is asked to sniff a familiar scent?

1 - olfactory

Which assessment finding leads a nurse to believe a patient is at risk for osteoporosis (Select All that Apply)?

A) Walks daily
B) Thin, white
C) Drinks cola
D) Smoker

B) Thin, white
C) Drinks cola
D) Smoker

What cranial nerve is being assessed when the nurse asks the patient to puff out their cheeks and then smile really big?

7 - Facial

What patient education should the nurse provide to a patient on asprin therapy? (Select All the Apply)

A) Instruct patient to tell dentist prior to dental work
B) Instruct patient to tell surgeon before any procedures
C) Instruct patient to double dose if one dose is missed
D) Instruct patient to avoid alcohol

A) Instruct patient to tell dentist prior to dental work
B) Instruct patient to tell surgeon before any procedures
D) Instruct patient to avoid alcohol

Which type of stroke or stroke damage is most likely to cause problems with respiratory distress related to neurologic function?

A) Frontal lobe damage
B) Thalamic stroke
C) Affected temporal lobe
D) Involvement of medulla and pons

D Involvement of medulla and pons

With what will a patient with a cerbellar dysfunction most likely need assistance?

A) Orientation to place and time
B) Buttoning the shirt
C) Verbal communication
D) Mood and pain control

B Buttoning the shirt

Which statement is included in an assessment of a patient's mental status?

A) Reports of pain, discomfort, or weakness
B) Ability to hear and see within normal limits
C) Appropriateness of clothes to weather conditions
D) Ability to push and pull against resistance

C Appropriateness of clothes to weather conditions

Which sensory assessment technique is correct?

A) Separate assessments for pain and temperature
B) Assessment of only the affected or injured sided
C) Assessment of the proximal and distal areas of extremeities
D) Assessment of sharp and dull senses by using a paper clip

D Assessment of sharp and dull senses by using a paper clip

An older adult patient is admitted into a long-term care facility and the nurse is performing a baseline physical assessment that includes neurologic and sensory function. What is the purpose of the assessment?

A) Determine a level of function for later
B) Show the family what problems the older adult has
C) Gain information on past sensory changes
D) Determine rehabilitation potential

A) Determine a level of function for later

What test is being performed when the patient walks across the room and returns?

A) Coordination
B) Muscle strength
C) Gait
D) Equilibrium

C) Gait

What motor testing is being performed when the patient stands, eyes closed, feet close together?

A) Coordination
B) Muscle strength
C) Gait
D) Equilibrium

D) Equilibrium

What motor testing is being performed when the patient grasps and squeezes the nurse's fingers?

A) Coordination
B) Muscle strength
C) Gait
D) Equilibrium

B) Muscle strength

The nursing student is performing a neurologic assessment on a patient who sustained a stroke. The nurse observes the student evaluating grip and hand strength only on the affected side. What is the nurse's first action?

A) Give the student positive feedback for performing the assessment correctly
B) Remind the student that strength testing needs to be done bilaterally
C) Redo the entire assessment and instruct the student to watch the process
D) Suggest to the instructor that the student needs remediation for assessment

B) Remind the student that strength testing needs to be done bilaterally

The nurse is attempting to assess a coma patient's response to pain. Which technique does the nurse try first?

A) Gently shake the patient, similar to attempting to wake a sleeping child
B) Speak to the patient and call his or her name using a normal tone of voice
C) Face the patient and speak loudly and clearly, similar to a hearing-impaired patient
D) Apply supraorbital pressure by placing the thumb under the orbital rim

B) Speak to the patient and call his or her name using a normal tone of voice

The nurse is assessing several patients using the GCS (Glasgow Coma Scale). Which factors indicate the most serious neurologic presentation based on the GCS information?

A) Eye opening to sound, localizes pain, confused conversation
B) Eye opening to sound, obeys commands, inappropriate words
C) Eye opening spontaneous, obeys commands, confused conversation
D) Eye opening to pain, abnormal flexion, incomprehensible sounds

D) Eye opening to pain, abnormal flexion, incomprehensible sounds

The nurse is performing neurologic checks every 4 hours for a patient who sustained a head injury. Which early sign indicates a decline in neurologic status?

A) Nonreactive, dilated pupils
B) Change in level of consciousness
C) Decorticate posturing
D) Loss of remote memory

B) Change in level of consciousness

The nursing student is talking to the patient and family about diagnostic testing. Which statement by the student indicates the need for further study about the understanding of diagnostic procedures?

A) You are scheduled for a magnetic resonance imaging (MRI). Do you have a cardiac pacemaker?
B) You are scheduled for a computed tomography (CT) of the head. Are you wearing hairpins?
C) You are to have x-rays of the skull. Are you allergic to iodine?
D) You are to have a cerebral angiography. Do you take medication for diabetes?

C) You are to have x-rays of the skull. Are you allergic to iodine?

Which statement about lumbar puncture is true?

A) It is indicated for patients with infections at or near the puncture site
B) It is done at the T1 to T3 spinal level
C) It requires the patient to lie flat for 24 - 48 hours after the procedure
D) It is done with the patient in the "fetal" position

D) It is done with the patient in the "fetal" position

What diagnostic testing would the nurse expect for a patient suspected of suffering an anurism?

Cerebral angiography

An elderly patient presents in the ER with confusion. What medical condition should be should out before suspecting permanent neurological problems?

Urinary tract infection

A patient is scheduled for an EEG. How does the nurse prepare the patient for this diagnostic test?

A) Giving a sedative before bedtime
B) Having the patient drink extra fluids before the test
C) Keeping the patient NPO after midnight
D) keeping the patient awake from 2 AM until the scheduled test time

D) keeping the patient awake from 2 AM until the scheduled test time

The nurse must be careful to assess the patient for allergies prior to a CT scan. True or False

True

The nurse has instructed the patient and family on on information about positron emission tomography (PET). However, the patient is suspected of having early signs of Alzheimer's disease. Which statement by the patient indicates he did not understand the information?

A) I may be aked to add or subract numbers or to remember things during the test
B) I am a little bit nervous about the idea of being blindfolded. Could you tell me about that?
C) They will not give me my insulin shot on the morning of the test
D) I will be asleep during most of the test; I will get a mild medication to help me relax.

D) I will be asleep during most of the test; I will get a mild medication to help me relax.

What type of diagnostic test involves the patient looking for expected patterens when introduced to a stimuli?

Visual evoked potentials

A patient is suffering from a spinal headache following a lumbar puncture test. What would the nurse expect to be provided to this patient to correct this condition?

Blood patch test

What type of headache is precipitated by a leaking of prostaglandins which causes inflammation and swelling?

migraine

Which headaches last longer; migraine or cluster headaches?

migraine

What type of medication can be used to prevent migraines?

A) Lamotrigine (Lamictal)
B) Metoclopramide (Reglan)
C) Sumatriptan (Imitrex)
D) Propranolol (Inderal)

D) Propranolol (Inderal)

What type of headache is caused by vasoreactivity and oxyhemoglobin desaturation?

Cluster

Which headache affects more men than women?

cluster

What types of drugs are considered for treating cluster headaches?

Same as migraines (Beta Blockers, Inderal; Antiepileptics, Topamax) as well as corticosteroids and lithium

What is a potential risk of cluster headaches that a nurse must be vigilant to look for?

Suicidal thoughts or tendencies.

At what point should treatment begin for migraine headaches?

Before headache starts; during aura phase

A patient presents with a severe headache that mainly is felt around the eye; what type of headache is this?

Cluster

A patient presents with a severe headache that mainly is felt as a band around the head; what type of headache is this?

migraine

A patient presents with bilateral pain at the base of the skull and forehead area; what type of headache is this?

tension

Treatment options for tension headaches include what?

Non-opiod analgesics (NSAIDs); Muscle relaxants, Ibuprofen plus caffeine

A patient with a history of migraine headaches reports his current headache as "my usual throbbing pain, but today it is behind my left eye." Which question does the nurse ask to elicit information about trigger factors?

A) Do you have a history of illicit substance abuse?
B) Do you smoke cigars or cigarettes?
C) Are you having any trouble with your vision?
D) Did you drink wine or coffee before the headache occured?

D) Did you drink wine or coffee before the headache occured?

During a patient's last visit, the nurse instructed the patient about headaches and techniques to manage this condition. Which statement by the patient indicates teaching has been successful?

A) I have been keeping track of when my headaches occur
B) My doctor told me that my headaches were not very serious
C) My spouse knows the instructsions that you gave me
D) I have not had any headaches since we last talked

A) I have been keeping track of when my headaches occur

A patient with a history of migraine headaches reports that light makes her "head hurt worse." How does the nurse document this subjective finding?

A) Patient reports photophobia
B) Patient reports phonophobia
C) Patient reports vertigo
D) Patient reports diplopia

A) Patient reports photophobia

The nurse is assessing a patient with Parkinson disease. Which cardinal findings does the nurse expect to observe? (Select All that Apply)

A) Tremors
B) Rigidity
C) Dementia
D) Aphasia
E) Postural instability
F) Slow movements

A) Tremors
B) Rigidity
E) Postural instability
F) Slow movements

A patient with Parkinson disease is being discharged on a selegiline (Eldepryl), which is a selective monamine oxidase type B (MAO-B) inhibitor. What information does the nurse include in the discharge teaching for the patient and family? Select all that apply

A) Take the medication with meals
B) Do not take tricyclic antidepressants while taking this medication
C) Avoid tyramine-rich foods such as aged or cured foods
D) Take the medication daily at bedtime
E) Do not take meperidine (Demerol) while taking this medication

B) Do not take tricyclic antidepressants while taking this medication
C) Avoid tyramine-rich foods such as aged or cured foods
E) Do not take meperidine (Demerol) while taking this medication

During the nurse's assessment of a patient with Parkinson disease, the nurse notes that the patient has masklike facies. What functional assessment is now a priority?

A) Pt's ability to hear normal voice tones
B) Ability to chew and swallow
C) Ability to sense pain in the facial area
D) Visual acuity

B) Ability to chew and swallow

A progressive neurodegenerative disease caused by a decrease of dopamine is called what?

Parkinson's Disease

An early sign of Parkinson's Disease is what?

A) Drooling
B) Soft Speech
C) Mask-like face
D) Tremors

B) Soft Speech

A potential nursing diagnosis for a Parkinson's patient experiencing excessive drooling would be what?

Risk for impaired body image

To obtain a postive Parkinson's Disease diagnosis what criteria must be met?

Patient must have two of the characteristic signs and patient is given a trial medication; if medication helps, diagnosis is confirmed

The surgical treatment for Parkinon's patients that involves burning tissues in the brain to ablate tissue in order to reduce muscles spasms is called what?

Stereotactic pallidotomy/thalamotomy

What is the first indication that central neurologic function has declined?

Level of consciousness

What five reflexes are tested for measuring deep tendong reflexes?

Patellar, Achilles, Biceps, Brachioradialis, Triceps

Dorsiflexion of the great toe and fanning of the other toes is called what?

Babinski's sign

During a client's neurologic assessment, the nurse finds that he is arousable only if his trapezius muscle is pinched. How will the nurse document this client's LOC?

A) Stuporous
B) Lethargic
C) Comatose
D) Drowsy

A) Stuporous

A client with possible Alzheimer's diesease is scheduled to have a positron emission tomography (PET) scan. The daughter asks the nurse how this test is different from a CT scan. What is the nurses's best response?

A) The PET scan is a newer test that can see the brain more clearly
B) The PET scan provides information about brain function rather than structure
C) The CT scan makes a lot of noise and the PET scan is quieter
D) The CT scan requires a contrast medium to be injected and the PET scan does not

B) The PET scan provides information about brain function rather than structure

The nurse is preparing a teaching plan for a client with migraine headaches who is receiving propranolol (Inderal) for migraine headaches. What health teaching by the nurse is important for the client?
A. "Take this drug only when you have symptoms at the beginning of a migraine headache."
B. "This drug is low dose, so you don't have to worry about your heart rate or blood pressure."
C. "This drug will relieve the pain during the aura phase soon after a headache has started."
D. "Take this drug as prescribed every day, even when feeling well, to prevent a migraine."

D. "Take this drug as prescribed every day, even when feeling well, to prevent a migraine."

A client with Alzheimer's disease asks the nurse to find her mother, who is decreased. What is the nurse's best response?
A. "Your mother died over 20 years ago."
B. "I'll find your mother as soon as I finish passing meds."
C. "What did your mother look like?"
D. "I'll ask your daughter to find your mother."

C. "What did your mother look like?"

Which nursing intervention is appropriate when caring for a client with Alzheimer's disease?
A. Provide a large clock and calendar.
B. Place the client in a geri-chair to prevent wandering.
C. Insert a urinary catheter to prevent incontinence.
D. Place the client in the nurse's station.

A. Provide a large clock and calendar.

The client newly diagnosed with Parkinson disease is being discharged. Which instruction is best for the nurse to provide to the client's spouse?
A) Administer medications promptly on schedule to maintain therapeutic drug levels.
B) Complete activities of daily living for the client.
C) Speak loudly for better understanding.
D) Provide high-calorie, high-carbohydrate foods to maintain the client's weight.

A) Administer medications promptly on schedule to maintain therapeutic drug levels.

The client has Parkinson disease (PD). Which nursing intervention best protects the client from injury?
A) Discouraging the client from activity
B) Encouraging the client to watch the feet when walking
C) Suggesting that the client obtain assistance in performing ADLs
D) Monitoring the client's sleep patterns

D) Monitoring the client's sleep patterns

The client with dementia and Alzheimer's disease is discharged to home. The client's daughter says, "He wanders so much, I am afraid he'll slip away from me." What resource does the nurse suggest?
A) Alzheimer's Wandering Association
B) National Alzheimer's Group
C) Safe Return Program
D) Lost Family Members Tracking Association

C) Safe Return Program

The client with a migraine is lying in a darkened room with a wet cloth on the head after receiving analgesic drugs. What will the nurse do next?
A) Allow the client to remain undisturbed.
B) Assess the client's vital signs.
C) Remove the cloth because it can harbor microorganisms.
D) Turn on the lights for a neurologic assessment.

A) Allow the client to remain undisturbed.

The nurse is teaching the client newly diagnosed with migraine about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan?
A) "I can still eat Chinese food."
B) "I must not miss meals."
C) "It is okay to drink a few wine coolers."
D) "I need to use fake sugar in my coffee."

B) "I must not miss meals."

The client with Parkinson disease is being discharged home with his wife. To ensure compliance with the management plan, which discharge action is most effective?
A) Involving the client and his wife in developing a plan of care
B) Setting up visitations by a home health nurse
C) Telling his wife what the client needs
D) Writing up a detailed plan of care according to standards

A) Involving the client and his wife in developing a plan of care

The home health nurse is checking in on the client with dementia and the client's spouse. The spouse confides to the nurse, "I am so tired and worn out." What is the nurse's best response?
A) "Can't you take care of your spouse?"
B) "Establishing goals and a daily plan can help."
C) "Make sure you take some time off and take care of yourself too."
D) "That's not a very nice thing to say."

C) "Make sure you take some time off and take care of yourself too."

The nurse is caring for the client with advanced Alzheimer's disease. Which communication technique is best to use with this client?
A) Providing the client with several choices to choose from
B) Assuming that the client is not totally confused
C) Waiting for the client to express a need
D) Writing down instructions for the client

B) Assuming that the client is not totally confused

The client is admitted into the emergency department with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring?
A) Stroke
B) Tension headache
C) Classic migraine
D) Cluster headache

C) Classic migraine

The female client with newly diagnosed migraine is being discharged with a prescription for sumatriptan (Imitrex). Which comment by the client indicates an understanding of the nurse's discharge instructions?
A) "Sumatriptan should be taken as a last resort."
B) "I must report any chest pain right away."
C) "Birth control is not needed while taking sumatriptan."
D) "St. John's wort can also be taken to help my symptoms."

B) "I must report any chest pain right away."

The nurse's friend fears that his mother is getting old, saying that she is becoming extremely forgetful and disoriented and is beginning to wander. What is the nurse's best response?
A) "Have you taken her for a checkup?"
B) "She has Alzheimer's disease."
C) "That is a normal part of aging."
D) "You should look into respite care."

A) "Have you taken her for a checkup?"

The client is being discharged to home with progressing stage I Alzheimer's disease. The family expresses concern to the nurse about caring for their parent. What is the priority for best continuity of care?
A) Assigning a case manager
B) Ensuring that all family questions are answered before discharge
C) Providing a safe environment
D) Referring the family to the Alzheimer's Association

A) Assigning a case manager

The spouse of the client with Alzheimer's disease (AD) is listening to the hospice nurse explaining the client's drug regimen. Which statement by the spouse indicates an understanding of the nurse's instruction?
A) "Donepezil (Aricept) will treat the symptoms of Alzheimer's disease."
B) "Memantine (Namenda)is indicated for treatment of early symptoms of Alzheimer's disease.
C) "Rivastigmine (Excelon) is used to treat depression."
D) "Sertraline (Zoloft) will treat the symptoms of Alzheimer's disease.''

A) "Donepezil (Aricept) will treat the symptoms of Alzheimer's disease."

The client with early-stage Alzheimer's disease is admitted to the surgical unit for a biopsy. Which client problem is the priority?
A) Potential for injury related to chronic confusion and physical deficits
B) Risk for reduced mobility related to progression of disability
C) Potential for skin breakdown related to immobility and/or impaired nutritional status
D) Lack of social contact related to personality and behavior changes

A) Potential for injury related to chronic confusion and physical deficits

The wife of the client with Alzheimer's disease mentions to the home health nurse that although she loves him, she is exhausted caring for her husband. What does the nurse suggest to alleviate caregiver stress?
A) Arranges for respite care
B) Provides positive reinforcement and support to the wife
C) Restrains the client for a short time each day, to allow the wife to rest
D) Teaches the client improved self-care

A) Arranges for respite care

The client has been diagnosed with Huntington disease. The nurse is teaching the client and her parents about the genetic aspects of the disease. Which statement made by the parents demonstrates a good understanding of the nurse's teaching?
A) "If she has children, she'll pass the gene on to her kids."
B) "She could only have gotten the disease from both of us."
C) "Because she got the gene from her father, she'll live longer than other people with the disease."
D) "More testing should definitely be done to see if she's really got the gene."

A) "If she has children, she'll pass the gene on to her kids."

The nursing instructor asks the student nurse caring for a client with Alzheimer's disease who has been prescribed donepezil (Aricept) how the drug works. Which response by the nursing student best explains the action of donepezil?
A) "The reuptake of serotonin is blocked."
B) "Donepezil prevents the increase in the protein beta amyloid."
C) "It delays the destruction of acetylcholine by acetylcholinesterase."
D) "Dopamine levels are increased."

C) "It delays the destruction of acetylcholine by acetylcholinesterase."

A client receiving sumatriptan (Imitrex) for migraine headaches is experiencing adverse effects after taking the drug. Which adverse effect is of greatest concern to the nurse?
A) Chest tightness
B) Skin flushing
C) Tingling feelings
D) Warm sensation

A) Chest tightness

Which change in the cerebrospinal fluid (CSF) indicates to the nurse that the client may have bacterial meningitis?
A) Cloudy, turbid CSF
B) Decreased white blood cells
C) Decreased protein
D) Increased glucose

A) Cloudy, turbid CSF

The nurse is about to administer a contrast medium to the client undergoing diagnostic testing. Which question will the nurse first ask the client?
A) "Are you allergic to iodine or shellfish?"
B) "Are you in pain?"
C) "Are you wearing any metal?"
D) "Do you know what this test is for?"

A) "Are you allergic to iodine or shellfish?"

The client has just returned from a cerebral angiography. Which symptom does the client display that causes the nurse to act immediately?
A) Bleeding
B) Increased temperature
C) Severe headache
D) Urge to void

A) Bleeding

The client has received contrast medium. Which teaching will the nurse provide to avoid any neurologic health problems after the procedure?
A) "Practice memory drills this afternoon."
B) "Drink at least 1000 to 1500 mL of water today."
C) "Avoid sunlight."
D) "Rest in bed for 24 hours."

B) "Drink at least 1000 to 1500 mL of water today."

The nurse is aware that which cranial nerve allows a person to feel a light breeze on the face?
A) I (olfactory)
B) III (oculomotor)
C) V (trigeminal)
D) VII (facial)

C) V (trigeminal)

The nurse is performing a neurologic assessment on an 81-year-old client. Which physiologic change does the nurse expect to find because of the client's age?
A) Decreased coordination
B) Increased sleeping during the night
C) Increased touch sensation
D) Stability in pain perception

A) Decreased coordination

The nurse prepares to assess a client with diabetes mellitus for sensory loss. Which equipment will the nurse need to perform this assessment?
A) Glucometer
B) Hammer
C) Nothing; the client is asked to walk
D) Paper clip

D) Paper clip

The nurse is performing a rapid neurologic assessment on a trauma client. Which assessment finding is normal?
A) Decerebrate posturing
B) Increased lethargy
C) Minimal response to stimulation
D) Constriction of pupils

D) Constriction of pupils

The nurse has just received report on a group of clients on the neurosurgical unit. Which client will be the nurse's first priority?
A) Young adult client whose Glasgow Coma Scale (GCS) rating has changed from 15 to 10
B) Adult client whose deep tendon reflexes have become hyperactive
C) Middle-aged client who displays plantar flexion when the bottom of the foot is stroked
D) Older adult client who consistently demonstrates decortication when stimulated

A) Young adult client whose Glasgow Coma Scale (GCS) rating has changed from 15 to 10

The nurse has just t received report on a group of clients. Which client will the nurse assess first?
A) Young adult who was in a car accident and has a 13 Glasgow Coma Scale score
B) Adult who had a cerebral arteriogram and has a cool, pale right leg
C) Middle-aged adult who has a headache after undergoing a lumbar puncture
D) Older adult who has expressive aphasia after a left-sided stroke

B) Adult who had a cerebral arteriogram and has a cool, pale right leg

The nurse is caring for a client who is scheduled to have a brain biopsy. The nurse anticipates that the health care provider will request which test before the brain biopsy is performed?
A) Lumbar puncture (LP)
B) Magnetic resonance imaging (MRI)
C) Skull x-ray
D) Transcranial Doppler ultrasonography (TCD)

B) Magnetic resonance imaging (MRI)

The nurse is instructing a client for whom a position emission tomography (PET) scan has been requested. Which statement indicates to the nurse that the client understands the instructions?
A) "It's okay to have a cup of coffee before the test."
B) "Because I am diabetic, I will take my insulin just before the test."
C) "I can continue to smoke cigarettes up to 2 hours before the test."
D) "I will drink plenty of fluids after the test."

D) "I will drink plenty of fluids after the test."

The nurse is assessing a client with a neurologic condition who is reporting difficulty chewing when eating foods. The nurse suspects that which cranial nerve has been affected?
A) Abducens nerve
B) Facial nerve
C) Trigeminal nerve
D) Trochlear nerve

sC) Trigeminal nerve

What stage of Alzheimer's is a patient in that begins displaying trouble with their finances?

Stage 2

Early or Stage 1 Alzheimer's typically lasts how long?

up to 4 years

An Alzheimer's patient with a decreased sense of smell would be considered to be in what phase of the disease?

Stage 1; Early

What is a limitation to the Mini Mental Status test?

Must be able to read

What cognitive assessment test can be given to an illiterate patient?

Set test

What hormone reacts to a decrease in calcium which signals to the kidnesy to deacrease the amount of calcium being realesed, also causes the gut to increase calcium absorption and triggers the bone to release more calcium?

Parathyroid hormone

What is stored in yellow marrow?

fat

What is an example of an immovable bone (synarthrodial)?

skull

What is an example of a slightl movable joint (amphiarthrodial)?

pelvis

What is an example of a freely movable joint (diathrodial)?

elbow

An example of a ball and socket joint?

shoulder, hip

Hinge joint?

elbow

Condyler?

knee

Biaxial?

wrist joints

Pivot?

C1 & C2 spine

Saddle?

thumb

What connects bone to bone?

ligament

What connects bone to muscle?

tendon

What joint contains a membrane that secretes synovial fluid?

knee

What type of muscle does the GI tract contain?

smooth

Whaty type of muscle is the heart muscle?

cardiac

What type of muscle are the voluntary muscles?

skeletal

What is an auto-immune disorder that affects the joints?

Rhumatoid arthritis

The beginning stages for a loss in bone denisity is called what?

Osteopenia

A significant loss of bone denisity is called what?

Osteoporosis

When bone, such as cervical bone collapses upon each other what is this called?

Crush factor

Synovial joint cartilage becomes more elastic with age, True or False?

False

What instrument is used to measure the flexion and extension or joint ROM?

Goniometer

The nurse observes a client's gait and notes that the client is displaying weigh bearing pain. How would this client's gait be described?

Antalgic gait

The nurse notes that a client has weakness during the swing phase of his gait. How would this be documented?

Lurch

A patient who stands with a "rolled over" posture is documeted as what?

Kyphosis

The prominent process at the base of the neck is what physical landmark?

C7 & T1

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