Identify 6 areas of a patient's past medical history that should be examined in a neurological
assessment. - correct answer History of head or spinal trauma or injuries
Chronic health problems
Surgical procedures
Medications
Personal habits
Family history
What types of past injuries should a nurse inquire about when performing a neurological
assessment? - correct answer head injuries, spinal cord injuries, peripheral nerve damage
What chronic health problems that are non-neurological in nature might be helpful in a
neurological assessment? - correct answer diabetes (can produce neuropathy), hyperlipidemia
(can produce stroke), hypertension (usually associated with increased ICP, could produce
stroke)
What past surgical procedures might contribute useful information in a neurological
assessment? - correct answer craniotomy, laminectomy, carotid endartectomy
What personal habits might provide insights in a neurological assessment? - correct answer
alcohol use, smoking, recreational drugs, chemical exposure
What information related to a patient's family history might be revealing in a neurological
assessment? - correct answer congenital defects (cerebral palsy--hypoxia; spina bifida--defect
resulting from incomplete closing of the embryonic neural tube), Huntington's disease (nerve
cells in certain parts of the brain waste away causing uncontrolled movements and mental
deterioration)
Identify 10 neurological symptoms. - correct answer headaches, seizures, syncope, pain,
paresthesia, gait disturbances, visual changes, vertigo, memory disorders, difficulty with
swallowing or speech
Identify the 5 areas that are included in assessing a patient's mental status. - correct answer
Level of awareness
Level of consciousness (LOC)
Behavior and appearance
Cognitive abilities
Emotional status
,Name 5 factors that are included in a general mental status screening. - correct answer Physical
appearance and behavior
Dress, grooming and personal hygeine
Facial expression
Affect
Communication
A patient is fully alert and knows their full name and the present time, but has no idea where
they are. Which of the following best characterizes this patient?
A) A&Ox1
B) A&Ox2
C) A&Ox3 - correct answer B) A&Ox2
A patient is fully alert and is aware of their full name, the present time and where they are.
Which of the following best characterizes this patient?
A) A&Ox1
B) A&Ox2
C) A&Ox3 - correct answer C) A&Ox3
What term describes an individual who is drowsy but will awaken in response to stimulation? -
correct answer lethargic (they do not fully awaken)
What term describes an individual who arouses to vigorous and continuous stimulation,
typically applied in the form of a painful stimulus? - correct answer stuporous
What term describes an individual who fails to respond to vigorous and continuous
stimulation? - correct answer comatose
A patient that is ________________ will open his eyes in response to deep pain.
stuporous
comatose - correct answer stuporous
A patient that is ________________ will not open his eyes in response to deep pain.
stuporous
comatose - correct answer comatose
,Identify the progression of strategies (4) that are used for eliciting a patient response. - correct
answer addressing the patient in a normal voice
addressing the patient in a loud voice
shaking the patient
applying a painful stimulus--proceed to the next measure in the progression if the patient fails
to respond
Name the 4 areas a nurse would apply a painful stimulus in efforts to elicit a response from an
unresponsive patient? - correct answer supraorbital pressure
trapezius squeeze
mandibular pressure
sternal rub
A painful stimulus is not required if a nurse has observed ______________________. - correct
answer spontaneous localization
Higher level cognitive functions are demonstrated by the ability to apply ______________ and
_______________. - correct answer abstract reasoning, judgment
A nurse asks a patient, "What do people mean when they say don't count your chickens before
they hatch?" The nurse intends to assess the patient's ______________________. - correct
answer abstract reasoning (the nurse will provide a proverb or metaphor that the patient must
explain)
A nurse asks a patient what he would do under a certain set of circumstances. The nurse
intends to assess the patient's ________________. - correct answer judgment
What is a screening assessment for cognitive impairment that includes orientation, registration,
attention and calculation, recall and language? - correct answer Mini-Mental State Exam
(MMSE)
A score of 24 on a Mini-Mental State Exam would indicate _________________. - correct
answer patients scoring greater than 23 indicates they have normal cognitive function
What is considered to be a normal score for the Mini-Mental State Exam? - correct answer >23
(30 is a perfect score)
A score of 20 on a Mini-Mental State Exam would indicate _________________. - correct
answer patients scoring less than 23 indicates cognitive impairment
, Would a patient that scores a 15 on a Mini-Mental State Exam be considered fit to give
informed consent? - correct answer No! They would not be considered competent due to
evidence of cognitive impairment.
A patient walks across the room and returns. What characteristic of motor testing was
performed? - correct answer gait
A patient stands, eyes open and feet together. What characteristic of motor testing was
performed? - correct answer equilibrium
A patient extends their arms to the side and tries to touch their nose two or three times. What
characteristic of motor testing was performed? - correct answer coordination
True or false. When a provider uses a soft, whispering voice to ask a patient to count to five, the
examiner is checking the patient's eighth cranial nerve. - correct answer true. The
vestibulocochlear nerve is responsible for hearing and equilibrium.
True or false. Taste is a function of both the seventh and ninth cranial nerves. - correct answer
true. The facial and glossopharyngeal nerves both have a role in the sensation of taste.
True or false. PERRLA is used to document extra-ocular movements. - correct answer false.
PERRLA is a means of pupillary assessment.
True or false. When a light is shined into one eye, the other pupil should also constrict. - correct
answer true. This is known as a consensual response.
True or false. During the interview process of a neurologic assessment, a healthcare provider
should ask, "Have you had a recent sinus infection?" - correct answer true
True or false. Mental status is an indicator of cerebral function. - correct answer true
True or false. Asking a patient to read a Snellen Chart will evaluate his fifth cranial nerve. -
correct answer false. The second cranial nerve is responsible for visual acuity and can be
evaluated with a Snellen Chart.
True or false. To check the first cranial nerve, ask the patient to identify an odor. - correct
answer true
True or false. About 20 percent of the population has a minimal or absent gag reflex. - correct
answer true
When assessing a patient with a head injury, what would be the proper order for proceeding
through the assessment process? - correct answer Airway, Breathing, Circulation, Deficit (A, B,
C, D)
Mnemonic for the names of cranial nerves - correct answer Oh Oh Oh To Touch And Feel Very
Green Vegetables AH
assessment. - correct answer History of head or spinal trauma or injuries
Chronic health problems
Surgical procedures
Medications
Personal habits
Family history
What types of past injuries should a nurse inquire about when performing a neurological
assessment? - correct answer head injuries, spinal cord injuries, peripheral nerve damage
What chronic health problems that are non-neurological in nature might be helpful in a
neurological assessment? - correct answer diabetes (can produce neuropathy), hyperlipidemia
(can produce stroke), hypertension (usually associated with increased ICP, could produce
stroke)
What past surgical procedures might contribute useful information in a neurological
assessment? - correct answer craniotomy, laminectomy, carotid endartectomy
What personal habits might provide insights in a neurological assessment? - correct answer
alcohol use, smoking, recreational drugs, chemical exposure
What information related to a patient's family history might be revealing in a neurological
assessment? - correct answer congenital defects (cerebral palsy--hypoxia; spina bifida--defect
resulting from incomplete closing of the embryonic neural tube), Huntington's disease (nerve
cells in certain parts of the brain waste away causing uncontrolled movements and mental
deterioration)
Identify 10 neurological symptoms. - correct answer headaches, seizures, syncope, pain,
paresthesia, gait disturbances, visual changes, vertigo, memory disorders, difficulty with
swallowing or speech
Identify the 5 areas that are included in assessing a patient's mental status. - correct answer
Level of awareness
Level of consciousness (LOC)
Behavior and appearance
Cognitive abilities
Emotional status
,Name 5 factors that are included in a general mental status screening. - correct answer Physical
appearance and behavior
Dress, grooming and personal hygeine
Facial expression
Affect
Communication
A patient is fully alert and knows their full name and the present time, but has no idea where
they are. Which of the following best characterizes this patient?
A) A&Ox1
B) A&Ox2
C) A&Ox3 - correct answer B) A&Ox2
A patient is fully alert and is aware of their full name, the present time and where they are.
Which of the following best characterizes this patient?
A) A&Ox1
B) A&Ox2
C) A&Ox3 - correct answer C) A&Ox3
What term describes an individual who is drowsy but will awaken in response to stimulation? -
correct answer lethargic (they do not fully awaken)
What term describes an individual who arouses to vigorous and continuous stimulation,
typically applied in the form of a painful stimulus? - correct answer stuporous
What term describes an individual who fails to respond to vigorous and continuous
stimulation? - correct answer comatose
A patient that is ________________ will open his eyes in response to deep pain.
stuporous
comatose - correct answer stuporous
A patient that is ________________ will not open his eyes in response to deep pain.
stuporous
comatose - correct answer comatose
,Identify the progression of strategies (4) that are used for eliciting a patient response. - correct
answer addressing the patient in a normal voice
addressing the patient in a loud voice
shaking the patient
applying a painful stimulus--proceed to the next measure in the progression if the patient fails
to respond
Name the 4 areas a nurse would apply a painful stimulus in efforts to elicit a response from an
unresponsive patient? - correct answer supraorbital pressure
trapezius squeeze
mandibular pressure
sternal rub
A painful stimulus is not required if a nurse has observed ______________________. - correct
answer spontaneous localization
Higher level cognitive functions are demonstrated by the ability to apply ______________ and
_______________. - correct answer abstract reasoning, judgment
A nurse asks a patient, "What do people mean when they say don't count your chickens before
they hatch?" The nurse intends to assess the patient's ______________________. - correct
answer abstract reasoning (the nurse will provide a proverb or metaphor that the patient must
explain)
A nurse asks a patient what he would do under a certain set of circumstances. The nurse
intends to assess the patient's ________________. - correct answer judgment
What is a screening assessment for cognitive impairment that includes orientation, registration,
attention and calculation, recall and language? - correct answer Mini-Mental State Exam
(MMSE)
A score of 24 on a Mini-Mental State Exam would indicate _________________. - correct
answer patients scoring greater than 23 indicates they have normal cognitive function
What is considered to be a normal score for the Mini-Mental State Exam? - correct answer >23
(30 is a perfect score)
A score of 20 on a Mini-Mental State Exam would indicate _________________. - correct
answer patients scoring less than 23 indicates cognitive impairment
, Would a patient that scores a 15 on a Mini-Mental State Exam be considered fit to give
informed consent? - correct answer No! They would not be considered competent due to
evidence of cognitive impairment.
A patient walks across the room and returns. What characteristic of motor testing was
performed? - correct answer gait
A patient stands, eyes open and feet together. What characteristic of motor testing was
performed? - correct answer equilibrium
A patient extends their arms to the side and tries to touch their nose two or three times. What
characteristic of motor testing was performed? - correct answer coordination
True or false. When a provider uses a soft, whispering voice to ask a patient to count to five, the
examiner is checking the patient's eighth cranial nerve. - correct answer true. The
vestibulocochlear nerve is responsible for hearing and equilibrium.
True or false. Taste is a function of both the seventh and ninth cranial nerves. - correct answer
true. The facial and glossopharyngeal nerves both have a role in the sensation of taste.
True or false. PERRLA is used to document extra-ocular movements. - correct answer false.
PERRLA is a means of pupillary assessment.
True or false. When a light is shined into one eye, the other pupil should also constrict. - correct
answer true. This is known as a consensual response.
True or false. During the interview process of a neurologic assessment, a healthcare provider
should ask, "Have you had a recent sinus infection?" - correct answer true
True or false. Mental status is an indicator of cerebral function. - correct answer true
True or false. Asking a patient to read a Snellen Chart will evaluate his fifth cranial nerve. -
correct answer false. The second cranial nerve is responsible for visual acuity and can be
evaluated with a Snellen Chart.
True or false. To check the first cranial nerve, ask the patient to identify an odor. - correct
answer true
True or false. About 20 percent of the population has a minimal or absent gag reflex. - correct
answer true
When assessing a patient with a head injury, what would be the proper order for proceeding
through the assessment process? - correct answer Airway, Breathing, Circulation, Deficit (A, B,
C, D)
Mnemonic for the names of cranial nerves - correct answer Oh Oh Oh To Touch And Feel Very
Green Vegetables AH
