Health Assessment

Health Assessment testbank The two parts of the nervous system are the - central and peripheral the wife of a 65 year old man tells the nurse that she is concerned because she has noticed a change in her husbands personality and ability to understand, He also cries very easily and and becomes angry. The nurse recalls that the central lobe responsible for the these behaviors is the _____ lobe. - frontal true or false the hypothalamus controls body temperature and regulates sleep - true the area of the nervous system that is responsible for mediating reflexes is the - spinal cord While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation, which of these areas must be intact? - lateral spinothalamic tract, thalamus, and sensory cortex A patient with a lack of oxygen to his heart will have pain in his chest and possibly in the shoulder, arms, or jaw. The nurse knows the best explanation why this occurs is which on of these statements? - The sensory cortex does not have the ability to localize pain in the heart; consequently the pain is felt elsewhere ` The ability that humans have to perform very skilled movements such as writing is controlled by the - corticospinal tract A 30 year old women tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse? - cerebellum true or false the peripheral nerves carry input to the central nervous system by afferent fibers and away from the central nervous system by efferent fibers - true A patient has a severed spinal nerve as a result of trauma. Which statement is true in this situation? - the adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve A 21 year old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patients deep tendon reflexes? - reflexes will be normal A mother of a 1 month old infant asks the nurse why it takes so long for infants to learn to roll over. The nurse knows the reason for this is - myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated During an assessment of a 80 year old patient. the nurse notices the following: an inability to identify vibrations at her ankle and to identify the position of her big toe, a slower and more deliberate gait and a slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate - normal changes attributable to aging A 70 year old women tells the nurse that every time she gets up in the morning or after she's been sitting, she gets really dizzy and feels like she is going to fall over. The nurses best response would be - you need to get up slowly when you've been lying down or sitting during the taking of health history the patient tells the nurse that it feels like the room is spinning around me. the nurse would document this finding as - vertigo when taking the health history on a patient with seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information? - do you have ant warning signs before your seizure starts? while obtaining a health history of a 3 month old infant from the mother, the nurse ask about the infants ability to suck and grasp the mothers finger. What is the nurse assessing? - reflexes in obtaining a health history on a 74 year old patient , the nurse notes that he drinks alcohol daily and that he has noticed tremors in his hands that affects his ability to hold things. with this information, what response should the nurse make? - does the tremor change when you drink alchohol. A 50 year old women is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination? - complete neurologic examination During an assessment of the cranial nerves, the nurse finds the following : asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids , and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these cranial nerves? - motor component of cranial nerve VII The nurse is testing the functional component of cranial nerve XI. Which statement best describes the response the nurse should expect if this nerve is intact? the patient: - moves the head and shoulders against resistance with equal strength. During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find? - mild, even resistance to movement When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as a(n): - positive Romberg sign The nurse is performing an assessment on a 29 year old women who visits the clinic complaining of always dropping things and falling down. While testing rapid alternating movements, the nurse notices that the women is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect? - dysfunction of the cerebellum During the taking of the health history of a 78-year old man, his wife states that he occasionally has problems with short term memory and confusion : He can't even remember how to button his shirt. When assessing his sensory system, which action by the nurse is most appropriate? - before testing, the nurse would assess the patients mental status and ability to follow directions