Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito)

Chapter 24 Neurologic System

1. The nurse is reviewing the cranial nerves. Which cranial nerves are sensory nerves? Select all that apply.

1. Olfactory nerve (cranial nerve I).

2. Optic nerve (cranial nerve II).

3. Trochlear nerve (cranial nerve IV).

4. Trigeminal nerve (cranial nerve V).

5. Facial nerve (cranial nerve VII).

Page Ref: 589, 590

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.1: Describe the anatomy and physiology of the neurologic system.

MNL Learning Outcome: 24.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system.

1. The nurse is caring for a client having problems with emotional appropriateness as a result of a brain injury. Based on this data, which area of the brain has been damaged?

1. Frontal lobe.

2. Parietal.

3. Occipital.

4. Temporal.

Page Ref: 587

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.6: Identify abnormal findings in the physical assessment of the neurologic system.

MNL Learning Outcome: 24.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system.

1. The nurse is caring for a client with a traumatic brain injury (TBI). The client begins to experience bradycardia. Which area of the brain is likely responsible for the changes in heart rate?

1. Brain stem.

2. Occipital lobe.

3. Parietal lobe.

4. Temporal lobe.

Page Ref: 747

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system.

MNL Learning Outcome: 24.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system.

1. The nurse is assessing a client's muscle tremors associated with Parkinson's disease. Which clinical finding does the nurse anticipate?

1. Fasciculations.

2. Chorea.

3. Rhythmic shaking.

4. Athetoid movements.

Page Ref: 625

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.6: Identify abnormal findings in the physical assessment of the neurologic system.

MNL Learning Outcome: 24.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system.

1. The nurse is performing a neurological assessment on a client experiencing anosmia. Which cranial nerve should the nurse assess?

1. Trochlear (cranial nerve IV).

2. Trigeminal (cranial nerve V).

3. Olfactory (cranial nerve I).

4. Oculomotor (cranial nerve III).

Page Ref: 599

Cognitive Level: Analyzing

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system.

MNL Learning Outcome: 24.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system.

1. The nurse is unable to elicit a patellar reflex on a client that is alert and oriented. Which action by the nurse is the most appropriate?

1. Document the findings as normal.

2. Notify the healthcare provider immediately.

3. Look at the medication records for central nervous system depressants.

4. Retest the reflex after having the client use distraction during the exam.

Page Ref: 616

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.4: Outline the techniques for assessment of the neurologic system.

MNL Learning Outcome: 24.3: Utilize the appropriate techniques and tools for physical assessment of the neurologic system.

1. The nurse is interviewing a client with suspected Lyme disease. Which question is the nurse's priority question?

1. "When was your last seizure?"

2. "Have you been hiking or camping lately?"

3. "What has your temperature been running?"

4. "Do you have an appetite?"

Page Ref: 624

Cognitive Level: Analyzing

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.5: Generate the appropriate documentation to describe the assessment of the neurologic system.

MNL Learning Outcome: 24.3: Utilize the appropriate techniques and tools for physical assessment of the neurologic system.

1. The nurse is preparing to conduct a focused interview on a client who is experiencing back pain. Which questions should the nurse include in the focused interview? Select all that apply.

1. "How long have you been experiencing this pain?"

2. "What activities seem to increase your pain?"

3. "Do you regularly engage in physical activity?"

4. "What things do you do to relieve your pain?"

5. "Are you receiving worker's compensation?"

Page Ref: 595

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.3: Determine which questions about the neurologic system to use for the focused interview.

MNL Learning Outcome: 24.3: Utilize the appropriate techniques and tools for physical assessment of the neurologic system.

1. The nurse is performing the Romberg's test and asks the client to stand with their feet together and eyes closed. Which is an expected finding during this assessment?

1. Swaying from side to side.

2. Exhibiting minimal swaying.

3. Feeling moderately dizzy.

4. Having complete loss of balance.

Page Ref: 608, 609

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.6: Identify abnormal findings in the physical assessment of the neurologic system.

MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.

1. The nurse is assessing a client that experienced a head injury using the Glasgow Coma Scale. Which findings reflect the motor response portion of the scale? Select all that apply.

1. No response with eyes to commands.

2. Abnormal flexion to pain.

3. Pupil response sluggish.

4. Abnormal extension to pain.

5. Pupils fixed and dilated.

Page Ref: 621

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.4: Outline the techniques for assessment of the neurologic system.

MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.

1. Which cranial nerve is the nurse testing using the technique to touch the client's face with a wisp of cotton while their eyes are closed?

1. Trigeminal nerve (cranial nerve V).

2. Abducens nerve (cranial nerve VI).

3. Facial nerve (cranial nerve VII).

4. Optic nerve (cranial nerve II).

Page Ref: 601

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.4: Outline the techniques for assessment of the neurologic system.

MNL Learning Outcome: 24.3: Utilize the appropriate techniques and tools for physical assessment of the neurologic system.

1. The nurse has tested a client's sense of smell. Which cranial nerve should the nurse document the findings?

1. I.

2. II.

3. III.

4. IV.

Page Ref: 600

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.5: Generate the appropriate documentation to describe the assessment of the neurologic system.

MNL Learning Outcome: 24.3: Utilize the appropriate techniques and tools for physical assessment of the neurologic system.

1. The nurse asks the client to stick their tongue out and move it back and forth. Which cranial nerve is the nurse assessing?

1. V.

2. VII.

3. X.

4. XII.

Page Ref: 607

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system.

MNL Learning Outcome: 24.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system.

1. Which instruction for the Romberg's test should the nurse provide the client?

1. "Touch your finger to your nose, alternating hands."

2. "Walk across the room by placing one foot in front of the other, heel to toes."

3. "Walk on your toes, then on your heels, and then on your toes again."

4. "Stand with your feet together, arms at sides, and eyes closed."

Page Ref: 609

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.4: Outline the techniques for assessment of the neurologic system.

MNL Learning Outcome: 24.3: Utilize the appropriate techniques and tools for physical assessment of the neurologic system.

1. The nurse is using stereognosis to assess a client. Which instruction would the nurse provide for the client?

1. "Tell me if you feel one or two objects touching you with your eyes closed."

2. "Identify the object in your hand with your eyes closed."

3. "Identify the number being traced in your hand with your eyes closed."

4. "Open and close your hand each time I tell you to."

Page Ref: 614

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.4: Outline the techniques for assessment of the neurologic system.

MNL Learning Outcome: 24.3: Utilize the appropriate techniques and tools for physical assessment of the neurologic system.

1. The nurse uses a reflex hammer to gently strike the forearm about two inches above the wrist. Which reflex is the nurse assessing?

1. Brachioradialis.

2. Biceps.

3. Triceps.

4. Achilles.

Page Ref: 618

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system.

MNL Learning Outcome: 24.3: Utilize the appropriate techniques and tools for physical assessment of the neurologic system.

1. The nurse reviewing records notes that a client has a positive Brudzinski's sign. Which clinical manifestation should the nurse recognize validates the assessment finding?

1. Seizure activity.

2. Neck pain and stiffness.

3. Flexion of the legs and thighs.

4. Neck extension.

Page Ref: 620

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.6: Identify abnormal findings in the physical assessment of the neurologic system.

MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.

1. The nurse is assessing cranial nerve XI (spinal accessory). Which statement should the nurse include in the instructions to the client to conduct the assessment?

1. "Shrug your shoulders and turn your head against my hand."

2. "Stick out your tongue and move it from side to side."

3. "Taste these foods and decide which is sweet and which is sour."

4. "Smell these items and identify what they are."

Page Ref: 606

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.4: Outline the techniques for assessment of the neurologic system.

MNL Learning Outcome: 24.3: Utilize the appropriate techniques and tools for physical assessment of the neurologic system.

1. The nurse is preparing to assess a client's ability to feel vibration, as well as sharp and dull sensation. Which equipment should the nurse use? Select all that apply.

1. Tuning fork.

2. Paper clip.

3. Safety pin.

4. Cotton ball.

5. Tongue blade.

Page Ref: 612, 613

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.4: Outline the techniques for assessment of the neurologic system.

MNL Learning Outcome: 24.3: Utilize the appropriate techniques and tools for physical assessment of the neurologic system.

1. The nurse has assessed a client and notes diminished reflexes. How would the nurse document this finding in the medical record?

1. 4+/0 - 4+.

2. 3+/0 - 4+.

3. 2+/0 - 4+.

4. 1+/0 - 4+.

Page Ref: 616

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.5: Generate the appropriate documentation to describe the assessment of the neurologic system.

MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.

1. The nurse is interviewing a client and notes that the left eyelid is drooping. Which term will the nurse use when documenting this finding in the medical record?

1. Ptosis.

2. Nystagmus.

3. Strabismus.

4. Myopia.

Page Ref: 600

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24.5: Generate the appropriate documentation to describe the assessment of the neurologic system.

MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.

1. A client is unable to perform a simple math calculation during a neurological examination. Which action should the nurse take?

1. Administer a different set of math problems.

2. Continue assessing the other cognitive domains.

3. Ask the client what grade they completed in school.

4. Verbally assess the client's ability to calculate a problem.

Page Ref: 598

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system.

MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.

1. The nurse notes that a client has difficulty with ambulation due to an unsteady gait. Which term will the nurse use to document this finding in the medical record?

1. Flaccidity.

2. Paralysis.

3. Hemiparesis.

4. Ataxia.

Page Ref: 622

Cognitive Level: Applying

Client Need & Sub: Physiological Mobility; Mobility/Immobility

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.5: Generate the appropriate documentation to describe the assessment of the neurologic system.

MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.

1. The nurse notes that a client has decreased sensation on the left side of their body. Which term should the nurse use in the documentation of the finding?

1. Anesthesia.

2. Analgesia.

3. Hypoalgesia.

4. Hypoesthesia.

Page Ref: 612

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24.5: Generate the appropriate documentation to describe the assessment of the neurologic system.

MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.

1. The client suspected of having meningitis verbalizes pain and stiffness in the neck when asked to flex their chin down toward their chest. Which terminology should the nurse use to document the finding?

1. Muscle spasms.

2. Neck strain.

3. Nuchal rigidity.

4. Brudzinski's sign.

Page Ref: 620

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24.5: Generate the appropriate documentation to describe the assessment of the neurologic system.

MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.

1. While interviewing a client, the nurse notes the client's eyes moving involuntarily. Which terminology should the nurse use to document the finding?

1. Nystagmus.

2. Presbyopia.

3. Anosmia.

4. Polyneuritis.

Page Ref: 600

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Physiological Adaptation

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24.5: Generate the appropriate documentation to describe the assessment of the neurologic system.

MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.

1. The nurse notes fanning of the toes when the sole of the foot is stimulated during assessment of the plantar reflex. Which term is appropriate for the nurse to use when documenting this finding in the medical record?

1. Hyperreflexia.

2. Babinski response.

3. Brudzinski's sign.

4. Nuchal rigidity.

Page Ref: 620

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Physiological Adaptation

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24.5: Generate the appropriate documentation to describe the assessment of the neurologic system.

MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.

1. The nurse is preparing a neurological health seminar for the staff on the unit. Which statement would the nurse include in the teaching plan?

1. Older adults lose the ability to taste and smell.

2. Alcohol or drug use increases the risk for neurological disorders.

3. Head injuries are more common in the young adult population.

4. Epilepsy generally occurs in children under age 15.

Page Ref: 595

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system.

MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.

1. The nurse is preparing to assess the oculomotor (III), trochlear (IV), and abducens cranial nerves (IV) of a client. Which tests should the nurse conduct? Select all that apply.

1. Visual acuity.

2. Peripheral vision.

3. Six cardinal points of gaze.

4. Convergence and accommodation.

5. Direct and consensual pupillary reaction to light.

Page Ref: 600

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24.4: Outline the techniques for assessment of the neurologic system.

MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.

1. The nurse is assessing the motor function of a client. Which finding should the nurse anticipate when the client performs the heel to shin test?

1. The client should be able to balance on one leg.

2. The client should be able to move their heel up their leg.

3. The client should be able to move their heel down the leg.

4. The client should be able to lift their heel to their lower leg.

Page Ref: 611

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system.

MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.

1. The nurse is assessing a client's triceps reflex. Which nerves should the nurse understand are being assessed?

1. C5 and C6.

2. C6 and C7.

3. L1 and L2.

4. L3 and L4.

Page Ref: 617

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24.1: Describe the anatomy and physiology of the neurologic system.

MNL Learning Outcome: 24.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system.

1. The nurse is observing a client's ambulation abilities and notes a scissors gait. Based on this data, which does the nurse suspect?

1. Parkinson's disease.

2. Multiple sclerosis.

3. Myasthenia gravis.

4. Muscular dystrophy.

Page Ref: 622

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.6: Identify abnormal findings in the physical assessment of the neurologic system.

MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.

1. The nurse is monitoring a client with a traumatic brain injury. Which statements made by the client are associated with the injury? Select all that apply.

1. "I have a headache."

2. "My joints feel very stiff and achy."

3. "I hear ringing in my ears."

4. "The light is bothering my eyes."

5. "My muscles feel very weak."

Page Ref: 623

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.6: Identify abnormal findings in the physical assessment of the neurologic system.

MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.

1. The nurse is caring for a client with Bell's palsy. In which cranial nerve should the nurse anticipate an abnormal finding?

1. Cranial nerve X.

2. Cranial nerve IX.

3. Cranial nerve VII.

4. Cranial nerve VIII.

Page Ref: 590

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 24.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system.

MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.

1. The nurse is performing a focused neurological assessment on a client. Which question should the nurse include when assessing the client's behaviors?

1. "Do you get headaches?"

2. "Do you need to write things down to remember them?"

3. "Can you tell me what brought you here today?"

4. "Are you currently taking any medications?"

Page Ref: 595

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Assessment

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.3: Determine which questions about the neurologic system to use for the focused interview.

MNL Learning Outcome: 24.2. Plan questions about the neurologic system for the focused interview.