PrepU ch.25 assessing neurologic system answer keys
PrepU ch.25 assessing neurologic system
Study online at https://quizlet.com/_9mpf05
1. The nurse plans to test which a. VIII
cranial nerve when testing an Explanation:
elderly client's hearing sta- Cranial nerve VIII contains sensory fibers for hearing and bal-
tus? ance.
Reference:
a.VIII Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th
b.VII ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing
c.VI Neurologic System, p. 571.
d.V Chapter 25: Assessing Neurologic System - Page 571
2. The nurse assesses the mo- b. Instruct the client to flex and extend the right elbow
tor system as part of the full Explanation:
neurological examination. In Instructing the client to flex and extend the right elbow is assess-
order to effectively assess ing strength, which is a part of the motor system assessment.
this system, which of the fol- Instructing the client to state the current date and place is part
lowing instructions should be of the mental status assessment. Instructing the client to smile
given to the client? and close the eyes is part of the cranial nerve assessment.
Reference:
a.Instruct the client to state Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th
the current date and place ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing
b.Instruct the client to flex Neurologic System, p. 579.
and extend the right elbow Chapter 25: Assessing Neurologic System - Page 579
c.Instruct the client to smile
d.Ask the client to close the
eyes
3. The nurse is performing the a. Client stands erect with minimal swaying
Romberg test. Which of the Explanation:
following indicate a normal The Romberg test is negative is the client stand erect with min-
finding? imal swaying with eyes both opened and closed. Balance when
walking is not part of the Romberg test.
a.Client stands erect with Reference:
Actualstudy 1 of 25
, PrepU ch.25 assessing neurologic system answer keys
PrepU ch.25 assessing neurologic system
Study online at https://quizlet.com/_9mpf05
minimal swaying Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th
b.Client sways when eyes are ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing
closed Neurologic System, p. 587.
c.Client prevents himself Chapter 25: Assessing Neurologic System - Page 587
from falling
d.Client maintains balance
when walking
4. The nurse documents a. Swaying
"Romberg test positive" on a Explanation:
client's medical record. What A positive Romberg test is when the client sways and moves the
did the nurse most likely as- feet apart to prevent falling. The Romberg test is not used to
sess in this client? assess gait, hand grasps, or the brachial reflex.
Reference:
a.Swaying Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th
b.Unsteady gait ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing
c.Weak hand grasps Neurologic System, p. 587.
d.Poor brachial reflex Chapter 25: Assessing Neurologic System - Page 587
5. The nurse observes the b. Temporal lobe herniation
Explanation:
client's pupils as shown (left
eye dilated pupil and rightA pupil that is fixed and dilated can indicate herniation of the
temporal lobe that causes compression of the oculomotor nerve
eye constricted pupil). What
should the nurse suspect isand midbrain. Pupils that are large and reactive are seen in
occurring with the client? cocaine or other sympathetic nervous system agonist drugs.
Pupils that are fixed in mid-position indicate structural damage
a.Cocaine use in the midbrain. Small or pinpoint pupils indicate damage to the
b.Temporal lobe herniation sympathetic pathways in the hypothalamus.
c.Structural damage in the Reference:
midbrain Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th
d.Damage to the sympathet- ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing
Actualstudy 2 of 25
, PrepU ch.25 assessing neurologic system answer keys
PrepU ch.25 assessing neurologic system
Study online at https://quizlet.com/_9mpf05
ic pathways in the hypothala- Neurologic System, p. 582.
mus Chapter 25: Assessing Neurologic System - Page 582
6. A 7-year-old boy is perform- c. Absence
ing poorly in school. His Explanation:
teacher is frustrated because This is a common description and scenario for absence seizures,
he is frequently seen "star- which are generally brief (fewer than 10 seconds, "petit mal").
ing off into space" and not They generally occur without warning and do not have a post-ic-
paying attention. If this is a tal confused state. Pseudoseizures are difficult to diagnose but
seizure, it most likely repre- generally involve dramatic-appearing movements, similar to ton-
sents which type? ic-clonic seizures. Myoclonus represents a single brief jerk of the
trunk and limbs.
a.Pseudoseizure Reference:
b.Tonic-clonic Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th
c.Absence ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing
d.Myoclonus Neurologic System, p. 573.
Chapter 25: Assessing Neurologic System - Page 573
7. A nurse performs a neuro- b. Dorsiflexion of the great toe and fanning of all toes
logic examination on a client Explanation:
who sustained an injury to An injury to the spinal cord or the brain causes abnormal pos-
the spinal cord. What find- turing in the client. This includes dorsiflexion of the great toe
ing should the nurse expect and fanning of all toes when the sole of the foot is stroked—a
when stroking the bottom of positive Babinski reflex—which is normal in newborns but in
the client's feet? adults is an indication of lesions of upper motor neurons or
unconscious states resulting from drug and alcohol intoxication,
a.Plantar flexion brain injury, or subsequent to an epileptic seizure. In the normal
b.Dorsiflexion of the great adult, the response to stroking the bottom of the foot is flexion of
toe and fanning of all toes the toes. Dorsiflexion and plantar flexion are not associated with
c.Dorsiflexion of the foot this reflex.
d.Flexion of the toes Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th
Actualstudy 3 of 25
PrepU ch.25 assessing neurologic system
Study online at https://quizlet.com/_9mpf05
1. The nurse plans to test which a. VIII
cranial nerve when testing an Explanation:
elderly client's hearing sta- Cranial nerve VIII contains sensory fibers for hearing and bal-
tus? ance.
Reference:
a.VIII Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th
b.VII ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing
c.VI Neurologic System, p. 571.
d.V Chapter 25: Assessing Neurologic System - Page 571
2. The nurse assesses the mo- b. Instruct the client to flex and extend the right elbow
tor system as part of the full Explanation:
neurological examination. In Instructing the client to flex and extend the right elbow is assess-
order to effectively assess ing strength, which is a part of the motor system assessment.
this system, which of the fol- Instructing the client to state the current date and place is part
lowing instructions should be of the mental status assessment. Instructing the client to smile
given to the client? and close the eyes is part of the cranial nerve assessment.
Reference:
a.Instruct the client to state Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th
the current date and place ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing
b.Instruct the client to flex Neurologic System, p. 579.
and extend the right elbow Chapter 25: Assessing Neurologic System - Page 579
c.Instruct the client to smile
d.Ask the client to close the
eyes
3. The nurse is performing the a. Client stands erect with minimal swaying
Romberg test. Which of the Explanation:
following indicate a normal The Romberg test is negative is the client stand erect with min-
finding? imal swaying with eyes both opened and closed. Balance when
walking is not part of the Romberg test.
a.Client stands erect with Reference:
Actualstudy 1 of 25
, PrepU ch.25 assessing neurologic system answer keys
PrepU ch.25 assessing neurologic system
Study online at https://quizlet.com/_9mpf05
minimal swaying Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th
b.Client sways when eyes are ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing
closed Neurologic System, p. 587.
c.Client prevents himself Chapter 25: Assessing Neurologic System - Page 587
from falling
d.Client maintains balance
when walking
4. The nurse documents a. Swaying
"Romberg test positive" on a Explanation:
client's medical record. What A positive Romberg test is when the client sways and moves the
did the nurse most likely as- feet apart to prevent falling. The Romberg test is not used to
sess in this client? assess gait, hand grasps, or the brachial reflex.
Reference:
a.Swaying Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th
b.Unsteady gait ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing
c.Weak hand grasps Neurologic System, p. 587.
d.Poor brachial reflex Chapter 25: Assessing Neurologic System - Page 587
5. The nurse observes the b. Temporal lobe herniation
Explanation:
client's pupils as shown (left
eye dilated pupil and rightA pupil that is fixed and dilated can indicate herniation of the
temporal lobe that causes compression of the oculomotor nerve
eye constricted pupil). What
should the nurse suspect isand midbrain. Pupils that are large and reactive are seen in
occurring with the client? cocaine or other sympathetic nervous system agonist drugs.
Pupils that are fixed in mid-position indicate structural damage
a.Cocaine use in the midbrain. Small or pinpoint pupils indicate damage to the
b.Temporal lobe herniation sympathetic pathways in the hypothalamus.
c.Structural damage in the Reference:
midbrain Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th
d.Damage to the sympathet- ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing
Actualstudy 2 of 25
, PrepU ch.25 assessing neurologic system answer keys
PrepU ch.25 assessing neurologic system
Study online at https://quizlet.com/_9mpf05
ic pathways in the hypothala- Neurologic System, p. 582.
mus Chapter 25: Assessing Neurologic System - Page 582
6. A 7-year-old boy is perform- c. Absence
ing poorly in school. His Explanation:
teacher is frustrated because This is a common description and scenario for absence seizures,
he is frequently seen "star- which are generally brief (fewer than 10 seconds, "petit mal").
ing off into space" and not They generally occur without warning and do not have a post-ic-
paying attention. If this is a tal confused state. Pseudoseizures are difficult to diagnose but
seizure, it most likely repre- generally involve dramatic-appearing movements, similar to ton-
sents which type? ic-clonic seizures. Myoclonus represents a single brief jerk of the
trunk and limbs.
a.Pseudoseizure Reference:
b.Tonic-clonic Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th
c.Absence ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing
d.Myoclonus Neurologic System, p. 573.
Chapter 25: Assessing Neurologic System - Page 573
7. A nurse performs a neuro- b. Dorsiflexion of the great toe and fanning of all toes
logic examination on a client Explanation:
who sustained an injury to An injury to the spinal cord or the brain causes abnormal pos-
the spinal cord. What find- turing in the client. This includes dorsiflexion of the great toe
ing should the nurse expect and fanning of all toes when the sole of the foot is stroked—a
when stroking the bottom of positive Babinski reflex—which is normal in newborns but in
the client's feet? adults is an indication of lesions of upper motor neurons or
unconscious states resulting from drug and alcohol intoxication,
a.Plantar flexion brain injury, or subsequent to an epileptic seizure. In the normal
b.Dorsiflexion of the great adult, the response to stroking the bottom of the foot is flexion of
toe and fanning of all toes the toes. Dorsiflexion and plantar flexion are not associated with
c.Dorsiflexion of the foot this reflex.
d.Flexion of the toes Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th
Actualstudy 3 of 25
