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Health Assessment Ch 15

Terms in this set (36)

A nurse assesses a patient with a head injury who has slowing intellectual functioning, personality changes, and emotional lability. The nurse correlates these findings with which area of the brain?
a. Frontal lobe
b. Parietal lobe
c. Thalamus
d. Temporal lobe
a. Frontal lobe (p 337)
In assessing a patient with damage to the occipital lobe, the nurse correlates which clinical manifestation to this injury?
a. Intentional tremors
b. Visual changes
c. Decreased hearing
d. Inability to formulate words
b. Visual changes (p 337)
While obtaining a symptom analysis from a patient who has an inner ear infection, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates vertigo?
a. "I felt lightheaded when I stood up."
b. "I just could not keep my balance when I sat up."
c. "It seemed that the room was spinning around."
d. "I was afraid that I was going to lose consciousness."
c. "It seemed that the room was spinning around." (p 344-345)
While obtaining a symptom analysis from a patient who had a transient ischemic attack, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates dizziness?
a. "I felt lightheaded when I stood up."
b. "It felt like I was on a merry-go-round."
c. "The room seemed to be spinning around."
d. "My body felt like it was revolving and could not stop."
a. "I felt lightheaded when I stood up." (p 344)
Which patient behavior indicates to the nurse that the patient's facial cranial nerve (CN VII) is intact?
a. The patient's eyes move to the left, right, up, down, and obliquely.
b. The patient moistens the lips with the tongue.
c. The sides of the mouth are symmetric when the patient smiles.
d. The patient's eyelids blink periodically.
c. The sides of the mouth are symmetric when the patient smiles. (p 352-353)
A nurse assessing a patient who had a cerebrovascular accident involving the Broca area suspects expressive or nonfluent aphasia. What communication abilities does the nurse anticipate from this patient?
a. The patient understands speech but is unable to translate ideas into meaningful speech.
b. The patient is unable to comprehend speech and thus does not respond verbally.
c. The patient is able to understand speech but has difficulty forming words, creating muffled speech.
d. The patient is unable to comprehend speech and responds inappropriately to conversation.
a. The patient understands speech but is unable to translate ideas into meaningful speech. (p 337, 339, 346)
The nurse hears in a report that a patient has receptive or fluent aphasia. What communication abilities does the nurse anticipate from this patient?
a. The patient understands speech but is unable to translate ideas into meaningful speech.
b. The patient is able to understand speech but has difficulty forming words creating muffled speech.
c. The patient is unable to comprehend speech and thus does not respond verbally.
d. The patient is emotionally liable and cries easily, which interferes with the ability to communicate.
c. The patient is unable to comprehend speech and thus does not respond verbally. ( 337, 339, 346)
What is the earliest and most sensitive indication of altered cerebral function?
a. Unequal pupils
b. Loss of deep tendon reflexes
c. Paralysis on one side of the body
d. Change in level of consciousness
d. Change in level of consciousness (p 347)
A patient reports having difficulty swallowing. Based on this information, how does the nurse assess the cranial nerve related to swallowing?
a. Ask the patient about feeling the blunt end of a paper clip along the jaw line.
b. Observe the rising of the soft palate when the patient says "Ahh."
c. Observe the symmetry of the face when the patient talks.
d. Assess taste on the anterior part of the tongue.
b. Observe the rising of the soft palate when the patient says "Ahh." (p 341, 346, 354)
A patient reports having difficulty swallowing. Based on this information, how does the nurse assess the appropriate cranial nerve?
a. Ask the patient to stick out the tongue and move it in all directions.
b. Ask the patient to move the head to the right and left.
c. Observe the symmetry of the face when the patient talks.
d. Assess for taste on the anterior part of the tongue.
a. Ask the patient to stick out the tongue and move it in all directions (p 341, 346, 354)
In assessing a patient's deep tendon reflexes, a nurse finds a patient has a 4+ triceps response. How does the nurse interpret this finding?
a. A hyperactive response
b. A diminished response
c. An absent response
d. An expected response
a. A hyperactive response (p 342-343, 349-350)
The nurse holds the patient's relaxed arm with elbow flexed at a 90-degree angle, places a thumb over a tendon in the antecubital fossa, and strikes the thumb with the pointed end of the reflex hammer. Which deep tendon reflex is the nurse assessing?
a. Brachioradialis
b. Biceps
c. Triceps
d. Deltoid
b. Biceps (p 342-343, 349-350)
A patient has a compression fracture of the cervical spine at C7 to C8 that is impairing deep tendon reflexes. Which response will the nurse expect from the affected deep tendon reflex?
a. Diminished to absent pronation of the arm
b. Diminished to absent flexion of the elbow
c. Diminished to absent extension of the elbow
d. Diminished to absent adduction of the upper arm
c. Diminished to absent extension of the elbow (p 342-343, 349-350)
A nurse holds the patient's relaxed left arm, with elbow flexed at a 90-degree angle, in one hand. The nurse palpates and then strikes the appropriate tendon just above the elbow with either end of the reflex hammer. What is the expected response for this deep tendon reflex?
a. Flexion of the left elbow
b. Pronation of the left forearm
c. Supination of the left arm
d. Extension of the left elbow
d. Extension of the left elbow (p 349-350)
A nurse holds the patient's relaxed arm with the elbow flexed at a 90-degree angle, places a thumb over the appropriate tendon in the antecubital fossa, and strikes the thumb with the pointed end of the reflex hammer. What is the expected response for this deep tendon reflex?
a. Flexion of the left elbow
b. Pronation of the left forearm
c. Supination of the left arm
d. Extension of the left elbow
d. Extension of the left elbow (p 349-350)
How does a nurse test the brachioradial deep tendon reflex?
a. Uses the end of the handle on the reflex hammer to stroke the lateral aspect of the sole of the patient's foot from heel to ball
b. Asks the patient to slightly pronate the relaxed forearm into the nurse's hand and strikes the appropriate tendon with the reflex hammer
c. Holds the patient's relaxed arm with the elbow flexed at a 90-degree angle in one hand, and palpates and strikes the appropriate tendon just above the elbow with the flat end of the reflex hammer
d. Holds the patient's relaxed arm with the elbow flexed at a 90-degree angle, places a thumb over the appropriate tendon in the antecubital fossa, and strikes the thumb with the pointed end of the reflex hammer
b. Asks the patient to slightly pronate the relaxed forearm into the nurse's hand and strikes the appropriate tendon with the reflex hammer (p 349-350)
A nurse dorsiflexes a patient's right ankle 90 degrees and then uses a reflex hammer to strike the appropriate tendon. What is the expected response for this deep tendon reflex?
a. Extension of the right lower leg
b. Plantar flexion of the right toes
c. Dorsiflexion of the right foot
d. Plantar flexion of the right foot
d. Plantar flexion of the right foot (p 349-350)
The nurse moves a wisp of cotton lightly across the anterior scalp, paranasal sinuses, and lower jaw to test the function of which cranial nerve?
a. CN IV (trochlear nerve)
b. CN V (trigeminal nerve)
c. CN VI (abducens nerve)
d. CN VII (facial nerve)
b. CN V (trigeminal nerve) (p 341, 352)
A nurse who is assessing a patient's eyes finds that the pupils are equal, round, and react to light and accommodation (PERRLA). These findings verify the expected functioning of which cranial nerve?
a. Optic cranial nerve (CN II)
b. Oculomotor cranial nerve (CN III)
c. Trochlear cranial nerve (CN IV)
d. Abducens cranial nerve (CN VI)
b. Oculomotor cranial nerve (CN III) (p 341, 352)
In assessing a patient with a tumor in the pons, the nurse expects to find which abnormalities due to pressure on cranial nerves?
a. Dilated pupils and ptosis
b. Facial asymmetry and impaired hearing
c. Difficulty swallowing
d. Impaired gag reflex
b. Facial asymmetry and impaired hearing (p 338, 341, 352)
The nurse assesses the glossopharyngeal nerve (CN IX) by testing which reflex?
a. Corneal reflex
b. Gag reflex
c. Blink reflex
d. Cough reflex
b. Gag reflex (p 341, 354)
Which cranial nerve is assessed when a nurse asks a patient to stick out the tongue and move it side to side?
a. Vagus nerve (CN X)
b. Facial nerve (CN VII)
c. Abducens nerve (CN VI)
d. Hypoglossal nerve (CN XII)
d. Hypoglossal nerve (CN XII) (p 341, 354)
As a patient is walking down the hall, the nurse notices the patient's staggering, unsteady gait. What findings does the nurse anticipate on the neurologic examination?
a. When the patient stands with feet together, eyes open and then closed, an upright posture is maintained.
b. When the patient touches the end of each finger to the thumb of the same hand, a tremor is observed in the fingers.
c. When the patient is giving a history to the nurse, a tremor is noticed as the patient's hands rest in the lap.
d. When lying supine, the patient is able to move the heel of one foot down the shin of the other leg.
b. When the patient touches the end of each finger to the thumb of the same hand, a tremor is observed in the fingers. (p 355)
A nurse asks the patient to stand with feet together, arms resting at the sides, with eyes open and then with the eyes closed. Which response by the patient indicates an expected cerebellar function?
a. Sways slightly and maintains upright posture with feet together
b. Is unable to stand upright after turning around in a circle once
c. Steps sideways when standing with feet together and eyes closed
d. Has to move arms horizontally to maintain balance
a. Sways slightly and maintains upright posture with feet together ( p 355)
The nurse asks the patient to stand with feet together, arms resting at the sides, with eyes open and then with the eyes closed. Which response by the patient indicates a problem in the cerebellum?
a. Maintains balance when eyes are open, but loses balance with eyes closed
b. Is unable to stand upright after turning around in a circle once
c. Steps sideways when standing with feet together and eyes closed
d. Sways slightly and maintains upright posture with feet together
c. Steps sideways when standing with feet together and eyes closed (p 355)
What is the patient's expected response when the nurse is assessing graphesthesia?
a. Lies supine and runs one heel along the opposite shin
b. Identifies a familiar object placed in the hands
c. Describes where a sensation of a vibrating tuning fork is felt
d. Identifies a letter or number drawn in the hand
d. Identifies a letter or number drawn in the hand (p. 359-360)
What is the patient's expected response when the nurse is assessing stereognosis?
a. Identifies an object placed in the hand
b. Distinguishes numbers or letters traced in the palm of the hand
c. Touches the index finger of the nondominant hand to the nose
d. Walks heel to toe in a straight line
a. Identifies an object placed in the hand (p 337, 359)
A nurse correlates a patient's altered stereognosis with a neurologic dysfunction in which part of the nervous system?
a. Midbrain or pons
b. Temporal lobe or ascending nerve tracts
c. Frontal lobe or motor nerve tracts
d. Parietal lobe or sensory nerve tracts
d. Parietal lobe or sensory nerve tracts (p 337, 339)
Which part of the nervous system is a nurse assessing when he places a vibrating tuning fork on a patient's wrist or ankle?
a. Frontal lobe and motor tracts
b. Parietal lobe and sensory tracts
c. Hypothalamus and sensory tracts
d. Cerebellum and motor tracts
b. Parietal lobe and sensory tracts (p 337, 340, 358-359)
A patient has a herniated disk compressing the lumbar spine at L2, L3, and L4 that is impairing deep tendon reflexes. Which response does a nurse expect from this patient?
a. Diminished contraction of the gastrocnemius muscle with plantar flexion of the foot
b. Diminished contraction of the quadriceps muscle with extension of the lower leg
c. Diminished plantar flexion of the toes
d. Diminished dorsiflexion of the foot and flexion of the toes
b. Diminished contraction of the quadriceps muscle with extension of the lower leg (p 343, 350)
What technique does the nurse use to test the patellar deep tendon reflex?
a. Using the end of the handle on the reflex hammer, the nurse strokes the lateral aspect of the sole of the patient's foot from heel to ball.
b. Ask the patient to flex one knee to 90 degrees, while the nurse dorsiflexes the ankle and strikes the appropriate tendon on the foot with the flat end of the reflex hammer.
c. Ask the patient to flex one knee to 45 degrees, while the nurse plantar flexes the ankle and strikes the appropriate tendon of the ankle with the pointed end of the reflex hammer.
d. Ask the patient to flex one knee to 90 degrees, while the nurse strikes the appropriate tendon in the knee with the blunt end of the reflex hammer.
d. Ask the patient to flex one knee to 90 degrees, while the nurse strikes the appropriate tendon in the knee with the blunt end of the reflex hammer. (p. 350)
What technique does the nurse use to test ankle clonus?
a. Strokes the lateral aspect of the sole of the patient's foot from heel to ball with a reflex hammer
b. Supports the patient's knee in flexed position and sharply dorsiflexes the foot and maintains the flexion
c. Plantar flexes the ankle and strikes the appropriate tendon of the ankle with the hammer
d. Everts the ankle and slowly moves the ankle into plantar flexion and quickly release the foot
b. Supports the patient's knee in flexed position and sharply dorsiflexes the foot and maintains the flexion (p 350)
Which response does a nurse expect when testing ankle clonus of a healthy woman?
a. No movement of the foot
b. Plantar flexion of the foot
c. Extension of the lower leg
d. Dorsiflexion of the foot
a. No movement of the foot (p 350)
To complete a symptom analysis, which questions does a nurse ask patient who recently had a seizure for the first time? Select all that apply.
a. "Did you have any warning signs before the seizure started?"
b. "Did you lose consciousness during the seizure?"
c. "Did the room seem to be spinning around before the seizure?"
d. "Did you urinate during the seizure?"
e. "What did you hear while you were seizing?"
f. "How did you feel after the seizure?"
a,b,d,f
Which characteristics are risk factors for cerebrovascular accident? Select all that apply.
a. Excessive alcohol intake
b. Smoking
c. Eating large amounts of smoked foods
d. Obesity
e. Atherosclerosis
f. High blood pressure
a,b,d,e,f
Which manifestations does a nurse correlate with a patient with suspected meningitis? Select all that apply.
a. Ptosis
b. Loss of balance when standing with feet together and the eyes closed
c. Confusion, agitation, and irritability
d. Severe headache
e. Stiff neck
f. Lethargy
c,d,e,f
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