Chapter 22: Neurological and Mental
Status
A client blinks when the right eye is lightly touched with a cotton wisp. Which cranial nerve
should the nurse document as being intact? - trigeminal
A client cannot differentiate between sharp and dull pain sensations when a nurse tests with a
safety pin. What is an appropriate action by the nurse? - Determine the ability to differentiate hot
and cold temperatures
A client has sustained an injury to the cerebellum. Which area should be the nurse's primary
focus for assessment? - Coordination
A client has sustained an injury to the cerebellum. Which area would be the primary area for
assessment? - coordination
A client presents to the emergency room after being hit in the face with a baseball. The health
care provider orders vision testing to be performed to assess the intactness of the cranial
nerves. The nurse should prepare to test which cranial nerves? Select all that apply. - abducens
trochlear
oculomotor
A client reports resting and skipping exercise during a holiday from work. Which part of the
nervous system is controlling this client's behavior? - parasympathetic
A client who was injured by a fall at a construction site has been admitted to the hospital. He
has suffered nerve damage such that his gag reflex is no longer intact, requiring him to receive
intravenous total parenteral nutrition. Which nerve should the nurse suspect to be involved in
this client's injury? - Glossopharyngeal (IX)
, A client's patellar reflex is normal for the right side but diminished on the left. Using the scale for
grading reflexes, how should the nurse document this finding? - Right knee +2; Left knee +1
A nurse cares for a client who suffered a cerebrovascular accident and demonstrates the
inability to speak clearly. The nurse recognizes that injury has occurred to what portion of the
brain? - broca's area
A nurse is assessing a client for abnormalities of gait due to a concern that the client is at
increased risk for a fall. Which instruction should the nurse give the client first? - "Walk across
the room and back."
A nurse is planning care for a client who has been diagnosed with restless leg syndrome. Which
intervention is the most effective for temporary relief of the symptoms? - exercising the legs
A nurse is preparing to offer a community education session on anxiety. Which part of the
nervous system should the nurse include in the discussion? - sympathetic nervous system
A nurse is reviewing a client's health record while interviewing her. The nurse sees in the client's
record a score of 3+ on the biceps reflex test from her previous visit. The nurse understands
that this finding indicates which of the following? - Increased or brisk, but not pathologic
A nurse performs a neurologic examination on a client who sustained an injury to the spinal
cord. What finding should the nurse expect when stroking the bottom of the client's feet? -
Plantar flexion
As adults age, peripheral nerve function and impulse conduction decrease. What is the result of
this decrease? - Decreased proprioception
Examination of a client's gait reveals that the client is stooped over when walking and that he
slowly shuffles. As well, the client maintains a stiff posture when walking. The nurse should
document what type of gait? - Parkinsonian gait
Status
A client blinks when the right eye is lightly touched with a cotton wisp. Which cranial nerve
should the nurse document as being intact? - trigeminal
A client cannot differentiate between sharp and dull pain sensations when a nurse tests with a
safety pin. What is an appropriate action by the nurse? - Determine the ability to differentiate hot
and cold temperatures
A client has sustained an injury to the cerebellum. Which area should be the nurse's primary
focus for assessment? - Coordination
A client has sustained an injury to the cerebellum. Which area would be the primary area for
assessment? - coordination
A client presents to the emergency room after being hit in the face with a baseball. The health
care provider orders vision testing to be performed to assess the intactness of the cranial
nerves. The nurse should prepare to test which cranial nerves? Select all that apply. - abducens
trochlear
oculomotor
A client reports resting and skipping exercise during a holiday from work. Which part of the
nervous system is controlling this client's behavior? - parasympathetic
A client who was injured by a fall at a construction site has been admitted to the hospital. He
has suffered nerve damage such that his gag reflex is no longer intact, requiring him to receive
intravenous total parenteral nutrition. Which nerve should the nurse suspect to be involved in
this client's injury? - Glossopharyngeal (IX)
, A client's patellar reflex is normal for the right side but diminished on the left. Using the scale for
grading reflexes, how should the nurse document this finding? - Right knee +2; Left knee +1
A nurse cares for a client who suffered a cerebrovascular accident and demonstrates the
inability to speak clearly. The nurse recognizes that injury has occurred to what portion of the
brain? - broca's area
A nurse is assessing a client for abnormalities of gait due to a concern that the client is at
increased risk for a fall. Which instruction should the nurse give the client first? - "Walk across
the room and back."
A nurse is planning care for a client who has been diagnosed with restless leg syndrome. Which
intervention is the most effective for temporary relief of the symptoms? - exercising the legs
A nurse is preparing to offer a community education session on anxiety. Which part of the
nervous system should the nurse include in the discussion? - sympathetic nervous system
A nurse is reviewing a client's health record while interviewing her. The nurse sees in the client's
record a score of 3+ on the biceps reflex test from her previous visit. The nurse understands
that this finding indicates which of the following? - Increased or brisk, but not pathologic
A nurse performs a neurologic examination on a client who sustained an injury to the spinal
cord. What finding should the nurse expect when stroking the bottom of the client's feet? -
Plantar flexion
As adults age, peripheral nerve function and impulse conduction decrease. What is the result of
this decrease? - Decreased proprioception
Examination of a client's gait reveals that the client is stooped over when walking and that he
slowly shuffles. As well, the client maintains a stiff posture when walking. The nurse should
document what type of gait? - Parkinsonian gait
