Health Assessment for Nursing Practice 6th Edition Chapter 15 Neurologic System

Health Assessment for Nursing Practice 6th Edition Chapter 15 Neurologic System. 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. ANS: C Feedback A This finding represents movement of the extraocular muscles, which are controlled by the oculomotor, trochlear, and abducens cranial nerves (CN III, IV, and VI, respectively). B This finding represents movement of the tongue, which is controlled by the hypoglossal cranial nerve (CN XII). C This finding represents facial symmetry, which is controlled by the facial cranial nerve (CN VII). D This finding represents function of the oculomotor cranial nerve (CN III). DIF: Cognitive Level: Apply REF: 352-353, Table 15-1 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 6. 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. ANS: A Feedback A The inability to translate ideas into meaningful speech or writing is termed expressive aphasia or nonfluent aphasia and is associated with lesions in the Broca area in the frontal lobe. B The inability to comprehend the speech of others is called receptive aphasia or fluent aphasia and is associated with lesions in the Wernicke area in the temporal lobe. C This speech pattern is more consistent with patients who have involvement of muscles of speech rather than neurologic deficits. D This speech pattern is not relevant to this patient. DIF: Cognitive Level: Apply REF: 337| 339| 346 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 7. 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. ANS: C Feedback A The inability to translate ideas into meaningful speech or writing is termed expressive aphasia or nonfluent aphasia and is associated with lesions in the Broca area in the frontal lobe. B This speech pattern is more consistent with patients who have involvement of muscles of speech rather than neurologic deficits. C This deficit is called receptive aphasia or fluent aphasia and is associated with lesions in the Wernicke area in the temporal lobe. D This speech pattern is not relevant to this patient. DIF: Cognitive Level: Apply REF: 337| 339| 346 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 8. 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 ANS: D Feedback A Pupillary function represents function of the oculomotor cranial nerve and the midbrain. B Deep tendon reflexes represent function of the spinal cord and reflex arcs. C Movement represents function of the spinal cord and posterior frontal lobe. D Maintaining consciousness represents the functions of and communication between the frontal lobe and reticular activating system. DIF: Cognitive Level: Remember REF: 347 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 9. 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.