Neurological Assessment Case Study
Neurological Assessment Case Study.pdf answer keys
Study online at https://quizlet.com/_9s80kn
1. The nurse begins the admission assessment with A, C, D, E
the collection of assessment data that is immediate-
ly entered into the electronic health record (EHR). Speech or swallowing difficul-
ties are changes that are as-
When eliciting data about possible neurological sociated with an increased risk
problems, what information should the nurse ob- of stroke. Headaches can indi-
tain from the client? (Select all that apply. One, cate hypertension or intracra-
some, or all options may be correct.) nial bleeding. Sensory function
is an important component of
A. Any difficulty speaking or swallowing. a neurological assessment be-
B. Ever hear voices that no one else hears. cause loss of sensation may in-
C. Headache frequency and location. dicate a stroke or neuropathy.
D. Any numbness,tingling, or weakness of extremi- Loss of consciousness, confu-
ties. sion, and intracranial bleeding
E. Did the head hit the floor with syncopal episode can occur as a result of a head
injury, so the nurse should de-
termine whether the client sus-
tained a head injury. The nurse
needs to examine the client for
raccoon eyes or a battle sign to
rule out a skull fracture. Also,
the nurse should note and re-
port any drainage from eyes,
ears,and/or nose to make sure
that it is not spinal fluid leaking.
Check for "halo sign" on bed
linens, which could also indi-
cate CSF leakage.
2. Based on the client's recent history of loss of con- D. Blood pressure and heart
sciousness and falling, what additional assessment rate and rhythm
takes priority?
Actualstudy 1
, Neurological Assessment Case Study
Neurological Assessment Case Study.pdf answer keys
Study online at https://quizlet.com/_9s80kn
Hypotension and bradycardia
A. Pedal pulse volume. can cause a loss of conscious-
B. Deep tendon reflexes. ness. Bradycardia may also be
C. Two-point discrimination. a sign of increased intracranial
D. Blood pressure and heart rate and rhythm pressure.If the client has hy-
pertension, it places the client
at increased risk for a hem-
orrhagic stroke. If the client
has cardiac irregularity, such
as atrial fibrillation, the client
should be evaluated and treat-
ed to prevent an embolic
stroke.
3. To determine what happened to the client prior to B, D, E
the loss of consciousness, the nurse should obtain
what information from the client? (Select all that B - This could indicate poor
apply. One, some, or all options may be correct.) cerebral perfusion due to hy-
potension or carotid occlusion,
A. Ask the client to stick out their tongue. which could cause loss of con-
B. Ask the client if they ever feel lightheaded or sciousness.
dizzy.
C. Ask the client if they have any problems with D - Postural hypotension oc-
smell. curs with position changes and
D. Ask the client if the dizziness occurs when they may cause a client to fall when
change positions. moving from a lying to sitting
E. Ask the client if they felt like the room was sud- position.
denly spinning before the fell
E - This indicates vertigo, which
is related to alterations of
vestibular apparatus in the ear.
If the nerve is damaged, the
Actualstudy 2
Neurological Assessment Case Study.pdf answer keys
Study online at https://quizlet.com/_9s80kn
1. The nurse begins the admission assessment with A, C, D, E
the collection of assessment data that is immediate-
ly entered into the electronic health record (EHR). Speech or swallowing difficul-
ties are changes that are as-
When eliciting data about possible neurological sociated with an increased risk
problems, what information should the nurse ob- of stroke. Headaches can indi-
tain from the client? (Select all that apply. One, cate hypertension or intracra-
some, or all options may be correct.) nial bleeding. Sensory function
is an important component of
A. Any difficulty speaking or swallowing. a neurological assessment be-
B. Ever hear voices that no one else hears. cause loss of sensation may in-
C. Headache frequency and location. dicate a stroke or neuropathy.
D. Any numbness,tingling, or weakness of extremi- Loss of consciousness, confu-
ties. sion, and intracranial bleeding
E. Did the head hit the floor with syncopal episode can occur as a result of a head
injury, so the nurse should de-
termine whether the client sus-
tained a head injury. The nurse
needs to examine the client for
raccoon eyes or a battle sign to
rule out a skull fracture. Also,
the nurse should note and re-
port any drainage from eyes,
ears,and/or nose to make sure
that it is not spinal fluid leaking.
Check for "halo sign" on bed
linens, which could also indi-
cate CSF leakage.
2. Based on the client's recent history of loss of con- D. Blood pressure and heart
sciousness and falling, what additional assessment rate and rhythm
takes priority?
Actualstudy 1
, Neurological Assessment Case Study
Neurological Assessment Case Study.pdf answer keys
Study online at https://quizlet.com/_9s80kn
Hypotension and bradycardia
A. Pedal pulse volume. can cause a loss of conscious-
B. Deep tendon reflexes. ness. Bradycardia may also be
C. Two-point discrimination. a sign of increased intracranial
D. Blood pressure and heart rate and rhythm pressure.If the client has hy-
pertension, it places the client
at increased risk for a hem-
orrhagic stroke. If the client
has cardiac irregularity, such
as atrial fibrillation, the client
should be evaluated and treat-
ed to prevent an embolic
stroke.
3. To determine what happened to the client prior to B, D, E
the loss of consciousness, the nurse should obtain
what information from the client? (Select all that B - This could indicate poor
apply. One, some, or all options may be correct.) cerebral perfusion due to hy-
potension or carotid occlusion,
A. Ask the client to stick out their tongue. which could cause loss of con-
B. Ask the client if they ever feel lightheaded or sciousness.
dizzy.
C. Ask the client if they have any problems with D - Postural hypotension oc-
smell. curs with position changes and
D. Ask the client if the dizziness occurs when they may cause a client to fall when
change positions. moving from a lying to sitting
E. Ask the client if they felt like the room was sud- position.
denly spinning before the fell
E - This indicates vertigo, which
is related to alterations of
vestibular apparatus in the ear.
If the nerve is damaged, the
Actualstudy 2
