Neurological Assessment HESI Case Study
Neurological Assessment HESI Case Study.pdf answer keys
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1. During a routine physical exam, a client reports ---
becoming increasingly forgetful and fears that
old age has arrived. The nurse notes that the
client has difficulty finishing some sentences,
forgetting common words and that the client is
wearing only a thin sweater on a very cold day.
The client is scheduled for more in-depth evalua-
tion for possible neurocognitive disorder due to
Alzheimer's disease
2. Communication and Documentation- --
The nurse begins the admission assessment
with the collection of assessment data that is
immediately entered into the EHR.
3. When eliciting data about possible neurological A. Any difficulty speaking or swal-
problems, what information should the nurse lowing
obtain from the client? (Select all that apply) (speech or swallowing difficulties
A.any difficulty speaking or swallowing are changes associated with in-
B.ever hear voices that no one else hears. creased risk of stroke)
C.Headache frequency and location.
D.Any numbness, tingling, or weakness of ex- C. Headache frequency and loca-
tremities. tion
E. did the head hit the floor with syncopal (headaches can indicate hyperten-
episode. sion or intracranial bleeding)
D.Any numbness, tingling, or weak-
ness of extremities.
(loss of sensation may indicate a
stroke or neuropathy)
Actualstudy 1
, Neurological Assessment HESI Case Study
Neurological Assessment HESI Case Study.pdf answer keys
Study online at https://quizlet.com/_bppwlb
E. Did the head hit the floor with
syncopal episode
4. Based on the client's recent history of loss of D. Blood Pressure, Heart Rate and
consciousness and falling, what additional as- Rhythm.
sessment takes priority? (hypotension and bradycardia can
A. Pedal Pulse Volume cause loss of consciousness)
B. Deep Tendon Reflexes
C. Two-Point Discrimination
D. Blood Pressure, Heart Rate and Rhythm.
5. The nurse assesses the client's vital signs and --
level of consciousness and then proceeds to in-
terview the client.
6. To determine what happened to the client prior B. Ask the client if they ever feel
to the loss of consciousness, the nurse should lightheaded or dizzy
obtain what information from the client? (select (could indicate poor cerebral per-
all that apply) fusion)
A. ask the client to stick out their tongue
B. ask the client if they ever feel lightheaded or D. Ask the client if the dizziness oc-
dizzy curs when they change positions
C. ask the client if they have any problems with (postural hypotension occurs with
smell position changes and may cause a
D. ask the client if the dizziness occurs when they client to fall when moving)
change positions
E. Ask the client if they felt like the
E. ask the client if they felt like the room was
room was suddenly spinning be-
suddenly spinning before the fall.
fore the fall.
(could indicate vertigo)
7. During the interview, the nurse observes the A. affirm the client's difficulty and
client's speech patterns. The client seems to ask about when this first started.
Actualstudy 2
Neurological Assessment HESI Case Study.pdf answer keys
Study online at https://quizlet.com/_bppwlb
1. During a routine physical exam, a client reports ---
becoming increasingly forgetful and fears that
old age has arrived. The nurse notes that the
client has difficulty finishing some sentences,
forgetting common words and that the client is
wearing only a thin sweater on a very cold day.
The client is scheduled for more in-depth evalua-
tion for possible neurocognitive disorder due to
Alzheimer's disease
2. Communication and Documentation- --
The nurse begins the admission assessment
with the collection of assessment data that is
immediately entered into the EHR.
3. When eliciting data about possible neurological A. Any difficulty speaking or swal-
problems, what information should the nurse lowing
obtain from the client? (Select all that apply) (speech or swallowing difficulties
A.any difficulty speaking or swallowing are changes associated with in-
B.ever hear voices that no one else hears. creased risk of stroke)
C.Headache frequency and location.
D.Any numbness, tingling, or weakness of ex- C. Headache frequency and loca-
tremities. tion
E. did the head hit the floor with syncopal (headaches can indicate hyperten-
episode. sion or intracranial bleeding)
D.Any numbness, tingling, or weak-
ness of extremities.
(loss of sensation may indicate a
stroke or neuropathy)
Actualstudy 1
, Neurological Assessment HESI Case Study
Neurological Assessment HESI Case Study.pdf answer keys
Study online at https://quizlet.com/_bppwlb
E. Did the head hit the floor with
syncopal episode
4. Based on the client's recent history of loss of D. Blood Pressure, Heart Rate and
consciousness and falling, what additional as- Rhythm.
sessment takes priority? (hypotension and bradycardia can
A. Pedal Pulse Volume cause loss of consciousness)
B. Deep Tendon Reflexes
C. Two-Point Discrimination
D. Blood Pressure, Heart Rate and Rhythm.
5. The nurse assesses the client's vital signs and --
level of consciousness and then proceeds to in-
terview the client.
6. To determine what happened to the client prior B. Ask the client if they ever feel
to the loss of consciousness, the nurse should lightheaded or dizzy
obtain what information from the client? (select (could indicate poor cerebral per-
all that apply) fusion)
A. ask the client to stick out their tongue
B. ask the client if they ever feel lightheaded or D. Ask the client if the dizziness oc-
dizzy curs when they change positions
C. ask the client if they have any problems with (postural hypotension occurs with
smell position changes and may cause a
D. ask the client if the dizziness occurs when they client to fall when moving)
change positions
E. Ask the client if they felt like the
E. ask the client if they felt like the room was
room was suddenly spinning be-
suddenly spinning before the fall.
fore the fall.
(could indicate vertigo)
7. During the interview, the nurse observes the A. affirm the client's difficulty and
client's speech patterns. The client seems to ask about when this first started.
Actualstudy 2
