Chapter 55 Assessment of Nervous System
Terms in this set (36)
When assessing a patient with a traumatic brain injury, the nurse notes uncoordinated movement of the extremities. How should the nurse document this assessment?
The nurse is performing a neurologic assessment for a patient. When assessing the accessory nerve, what action should the nurse take?
Ask the patient to shrug the shoulders against resistance
When assessing motor function of a patient admitted with a stroke, the nurse notes mild weakness of the arm. The patient also is unable to hold the arm level. How should the nurse most accurately document this finding?
A patient's sudden onset of hemiplegia has necessitated a CT scan of her head. Which action should be the nurse's priority before this diagnostic study?
Assess the patient for allergies to shellfish, iodine, or dyes.
The nurse is caring for a patient with a neurologic disease that affects the pyramidal tract. What clinical manifestation does the nurse assess in this patient?
Impaired muscle movement
How should the nurse most accurately assess the position sense of a patient with a recent traumatic brain injury?
Ask the patient to stand with the feet together and eyes closed and observe for balance maintenance.
The nurse is admitting a patient with a diagnosis of frontal lobe dementia. What functional difficulties should the nurse expect in this patient?
Higher cognitive function abnormalities
A patient is having a transsphenoidal hypophysectomy. The nurse should provide preoperative patient teaching about what potential deficit as a result of the surgery?
Altered sense of smell
The nurse is preparing the patient for an electromyogram (EMG). What should the nurse include in teaching the patient before the test?
The pain that occurs is from the insertion of the needles
The nurse is caring for a group of healthy older adults at a community day center. Which neurologic finding associated with aging would the nurse expect to note in older adults?
The nurse is completing a health assessment for a newly admitted patient. Which assessment should the nurse perform to determine the cognitive function of the patient?
Ask the patient a question such as, "Who were the last three presidents?"
In which patient would it be the most important for the nurse to assess the glossopharyngeal and vagus nerves?
A 50-yr-old woman with lethargy from a drug overdose
The nurse is caring for a patient after a lumbar puncture. Which is a priority action by the nurse
Assess for drainage or bleeding from the puncture site
A patient with heart failure and type 1 diabetes mellitus is scheduled for a positron emission tomogram (PET) of the brain. Which medication prescribed by the health care provider should the nurse expect to administer before the diagnostic study?
Regular insulin 6 units (SQ)
The nurse is caring for an older adult patient. Which normal nervous system changes of aging put this patient at higher risk of falls (select all that apply.)?
Motor function deficit
Central nervous system changes
When admitting an acutely confused patient with a head injury, which action should the nurse take?
Ask family members about the patient's health history
Which finding would the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion?
The nurse performing a focused assessment of left posterior temporal lobe functions will assess the patient for
Ability to understand written and oral language
Propranolol (Inderal), a -adrenergic blocker that inhibits sympathetic nervous system activity, is prescribed for a patient who has extreme anxiety about public speaking. The nurse monitors the patient for
To assess the functions of the trigeminal and facial nerves (CNs V and VII), the nurse should
Touch a cotton wisp strand to the cornea
Which action will the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)?
Withhold oral fluids and food
An unconscious male patient has just arrived in the emergency department with a head injury caused by a motorcycle crash. Which order should the nurse question?
Prepare the patient for lumbar puncture
A patient with suspected meningitis is scheduled for a lumbar puncture. Before the procedure, the nurse will plan to
Help the patient to a lateral position
During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurse's directions to move his hands and feet. The nurse will suspect
Frontal lobe damage
A patient has a tumor in the cerebellum. The nurse will plan interventions to
Which problem can the nurse expect for a patient who has a positive Romberg test result?
The nurse will anticipate teaching a patient with a possible seizure disorder about which test?
Which nursing action will be included in the plan of care for a patient who has had cerebral angiography?
Check pulse and blood pressure frequently
Which equipment will the nurse obtain to assess vibration sense in a patient with diabetes who has peripheral nerve dysfunction?
Which information about a 76-year-old patient should the nurse report as uncharacteristic of normal aging?
Unintended weight loss of 15 pounds
The charge nurse is observing a new staff nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action indicates a need for further teaching of the new nurse about neurologic assessment?
The new nurse asks the patient if the instrument feels sharp
Which cerebrospinal fluid analysis result should the nurse recognize as abnormal and communicate to the health care provider?
Protein of 65 mg/dL (0.65 g/L)
A 39-year-old patient with a suspected herniated intervertebral disc is scheduled for a myelogram. Which information communicated by the nurse to the health provider before the procedure would change the procedural plans?
The patient reports a previous allergy to shellfish
The priority nursing assessment for a patient being admitted with a brainstem infarction is
Several patients have been hospitalized for diagnosis of neurologic problems. Which patient will the nurse assess first?
A patient with a brain tumor who has just arrived on the unit after a cerebral angiogram
Which assessments will the nurse make to monitor a patient's cerebellar function (select all that apply)?
Observe arm swing with gait
Perform the finger-to-nose test
YOU MIGHT ALSO LIKE...
EMT Basic Exam | Mometrix Comprehensive Guide
Med Surg II Ch. 56
MED/SURG: Chapter 57
MedSurg Ch. 61
OTHER SETS BY THIS CREATOR
Kaplan Trainer 1 - NCLEX Review
NCLEX STUDY Kaplan Trainer 2
NCLEX Question Trainer 5
Kaplan Question Trainer 3
THIS SET IS OFTEN IN FOLDERS WITH...
Lewis 10th Chapter 58 Chronic Neurologic Problems Evolve NCLEX practice
Chapter 55 - Nervous System
Chapter 55 (Lewis): Nervous System
Lewis 10th Chapter 55 Assessment of Nervous System