Ch24 Neurologic System

1. When the nurse is educating Mr. Phelps, she should include information regarding the use of safety equipment, including seat belts, because older adults have decreased reaction time, resulting in accident and injury.

True

False

Based on Healthy People 2010, older adults have decreased reaction time, resulting in accident and injury; therefore, the nurse should stress safety, including use of seat belts while traveling in a car or driving, and the use of safety devices in the home and at work.

Explanation

Based on Healthy People 2010, older adults have decreased reaction time, resulting in accident and injury; therefore, the nurse should stress safety, including use of seat belts while traveling in a car or driving, and the use of safety devices in the home and at work.

2. A client has a history of anosmia over the past three months. The nurse knows that this condition is:

Related to swallowing difficulty

Associated with ataxia

Difficulty with tongue movements

Loss of ability to smell or detect odors

Anosmia, the absence of the sense of smell, may be due to cranial nerve dysfunction, colds, rhinitis, or zinc deficiency, or it may be genetic.

Difficulty in swallowing is called dysphagia.

Ataxia is an unsteady gait.

Difficulty with tongue movements may cause problems with swallowing or speech.

Explanation

Anosmia, the absence of the sense of smell, may be due to cranial nerve dysfunction, colds, rhinitis, or zinc deficiency, or it may be genetic.

Difficulty in swallowing is called dysphagia.

Ataxia is an unsteady gait.

Difficulty with tongue movements may cause problems with swallowing or speech.

3. The nurse asks a client to stand with feet together and arms at the side with eyes closed. The client immediately starts to sway and moves his feet farther apart. The nurse would document this as a:

Negative Romberg's sign

Positive Romberg's sign

Cerebellar dysfunction

Vestibular dysfunction

A positive Romberg's sign occurs when swaying greatly increases or the client falls when standing with feet together and eyes closed. This test assesses the vestibular apparatus and posterior columns of the spinal cord.

A normal response, Romberg negative, means that the client can stand with feet together and eyes closed with minimal swaying.

Although both the cerebellum and the vestibular apparatus are being assessed with this test, the nurse would not diagnose dysfunction with either structure based on this one finding.

Explanation

A positive Romberg's sign occurs when swaying greatly increases or the client falls when standing with feet together and eyes closed. This test assesses the vestibular apparatus and posterior columns of the spinal cord.

A normal response, Romberg negative, means that the client can stand with feet together and eyes closed with minimal swaying.

Although both the cerebellum and the vestibular apparatus are being assessed with this test, the nurse would not diagnose dysfunction with either structure based on this one finding.

4. A client has a flattened nasolabial fold and drooping of the mouth on the left side. Which of the following cranial nerves is most likely to be involved?

Cranial nerve V (Trigeminal)

Cranial nerve VII (Facial)

Cranial nerve XII (Hypoglossal)

Cranial nerve XI (Accessory)

Cranial nerve VII (Facial) is responsible for symmetry of facial expressions such as smiling, frowning, and puffing of the cheeks.

Cranial nerve V (Trigeminal) is responsible for facial sensation and temporal and masseter muscle strength.

Cranial nerve XII (Hypoglossal) is responsible for movements of the tongue and protrusion of the tongue in the midline.

Cranial nerve XI (Accessory) is responsible for sternocleidomastoid and trapezius muscle strength.

Explanation

Cranial nerve VII (Facial) is responsible for symmetry of facial expressions such as smiling, frowning, and puffing of the cheeks.

Cranial nerve V (Trigeminal) is responsible for facial sensation and temporal and masseter muscle strength.

Cranial nerve XII (Hypoglossal) is responsible for movements of the tongue and protrusion of the tongue in the midline.

Cranial nerve XI (Accessory) is responsible for sternocleidomastoid and trapezius muscle strength.

5. An elderly client is experiencing an alteration in his equilibrium and coordinated muscle movements. The nurse realizes that these functions are controlled by which area of the nervous system?

Cerebrum

Hypothalamus

Cerebellum

Brainstem

The cerebellum is located below the cerebrum and behind the brain stem. It coordinates stimuli from the cerebral cortex to provide precise timing for skeletal muscle coordination and smooth movements. The cerebellum also assists with maintaining equilibrium and muscle tone.

The cerebrum is responsible for all conscious behavior and consists of the frontal, parietal, occipital, and temporal lobes.

The hypothalamus is the autonomic control center and influences blood pressure, heart rate, digestive motility, respirations, regulation of body temperature, water balance, and sleep cycles.

The brainstem controls blood pressure, respiratory rate, swallowing, and coughing.

Explanation

The cerebellum is located below the cerebrum and behind the brain stem. It coordinates stimuli from the cerebral cortex to provide precise timing for skeletal muscle coordination and smooth movements. The cerebellum also assists with maintaining equilibrium and muscle tone.

The cerebrum is responsible for all conscious behavior and consists of the frontal, parietal, occipital, and temporal lobes.

The hypothalamus is the autonomic control center and influences blood pressure, heart rate, digestive motility, respirations, regulation of body temperature, water balance, and sleep cycles.

The brainstem controls blood pressure, respiratory rate, swallowing, and coughing.

6. During the interview, the nurse notes several problems that Mr. Phelps has experienced, leading to Parkinson's syndrome, that have affected his musculoskeletal system. Which of the following nursing diagnoses would be the most important when the client complains of shuffling gait, falls easily, and has poor posture with forward flexion?

Pain, chronic related to disease process

Falls, risk for

Skin integrity, impaired

Mobility, wheelchair impaired

Pain is an important nursing diagnosis, but based on the information presented (shuffling gait, falls easily, and poor posture with forward flexion) , this is not a priority nursing diagnosis.

Explanation

Pain is an important nursing diagnosis, but based on the information presented (shuffling gait, falls easily, and poor posture with forward flexion) , this is not a priority nursing diagnosis.

7. The nurse asks the client to close their eyes, then moves the client's finger up and down. The client identifies the direction of movement. Which of the following is being tested?

Stereognosis

Topognosis

Kinesthesia

Graphesthesia

Kinesthesia is awareness of position and sense of joint movement. The client should be able to identify the direction of movement with their eyes closed.

Stereognosis is the ability to identify an object placed in the hand with eyes closed.

Graphesthesia is the ability to perceive writing on the skin.

Topognosis is the ability of the client to identify an area of the body that has been touched.

Explanation

Kinesthesia is awareness of position and sense of joint movement. The client should be able to identify the direction of movement with their eyes closed.

Stereognosis is the ability to identify an object placed in the hand with eyes closed.

Graphesthesia is the ability to perceive writing on the skin.

Topognosis is the ability of the client to identify an area of the body that has been touched.

8. During an assessment of an adult client's plantar reflex, the nurse notes a normal response. Which of the following would be considered normal for this client?

Babinski response

Dorsiflexion of the foot

Plantar flexion of the foot

Fanning of the toes

When assessing the plantar reflex, observe for plantar flexion where the toes curl toward the sole of the foot.

The Babinski response is dorsiflexion of the great toe and fanning of the other toes when eliciting the plantar reflex. The Babinski response is considered abnormal in an adult and may indicate upper motor neuron disease. A positive Babinski response is considered a normal response in a child until about 2 years of age.

Dorsiflexion of the foot is not a normal plantar reflex response.

Fanning of the toes occurs with a positive Babinski.

Explanation

When assessing the plantar reflex, observe for plantar flexion where the toes curl toward the sole of the foot.

The Babinski response is dorsiflexion of the great toe and fanning of the other toes when eliciting the plantar reflex. The Babinski response is considered abnormal in an adult and may indicate upper motor neuron disease. A positive Babinski response is considered a normal response in a child until about 2 years of age.

Dorsiflexion of the foot is not a normal plantar reflex response.

Fanning of the toes occurs with a positive Babinski.

9. Because Mr. Phelps has difficulty with his gait, the nurse should encourage using throw rugs around the house to help cover electrical cords and extension cords to prevent injury.

True

False

The nurse should explain to the client that the risk of injury from falls can be reduced in the home by removing throw rugs and installing handrails and grab bars.

Explanation

The nurse should explain to the client that the risk of injury from falls can be reduced in the home by removing throw rugs and installing handrails and grab bars.

10. The nurse is performing an assessment on a 40-year-old client and is unable to elicit a patellar reflex. Which of the following is the most appropriate initial action?

Utilize reinforcement techniques that enhance the reflex.

Complete the remainder of the assessment, then reassess the reflexes.

Consider this a normal finding for a client of this age.

Before concluding that a reflex is absent or diminished, repeat the test. Encourage the client to relax. Asking the client to perform an isometric activity of a distant muscle group, which is called reinforcement, helps relax the muscle and enhance the reflex. Before documenting a 0/0-4 (absent) reflex, the nurse needs to reassess the reflex.

The nurse should reassess the reflex utilizing reinforcement techniques, not continue with the assessment and save the reflexes until the end.

The patellar reflex should be present in all age groups; however, it may be weaker in the elderly.

Explanation

Before concluding that a reflex is absent or diminished, repeat the test. Encourage the client to relax. Asking the client to perform an isometric activity of a distant muscle group, which is called reinforcement, helps relax the muscle and enhance the reflex. Before documenting a 0/0-4 (absent) reflex, the nurse needs to reassess the reflex.

The nurse should reassess the reflex utilizing reinforcement techniques, not continue with the assessment and save the reflexes until the end.

The patellar reflex should be present in all age groups; however, it may be weaker in the elderly.

11. Near the conclusion of the neurologic examination, the nurse notices a rapid muscle contraction of the client's left quadriceps muscle. Which of the following could describe this assessment finding?

This is a fasciculation.

This is a tic.

This is a tremor.

This is myoclonus.

A fasciculation, or twitch, is an involuntary local visible muscular contraction that is not significant when it occurs with tired muscles. It can also be associated with motor neuron disease.

A tic, commonly called a habit, is usually psychogenic in nature. Tics are usually seen in the face, neck, or shoulders and increase during times of stress.

Tremors are rhythmic or alternating involuntary movements caused by the contraction of opposing muscle groups.

Myoclonus is a continual, rapid, short spasm involving a muscle, a part of a muscle, or even a group of muscles. Myoclonus frequently occurs in an extremity as the individual is falling asleep.

Explanation

A fasciculation, or twitch, is an involuntary local visible muscular contraction that is not significant when it occurs with tired muscles. It can also be associated with motor neuron disease.

A tic, commonly called a habit, is usually psychogenic in nature. Tics are usually seen in the face, neck, or shoulders and increase during times of stress.

Tremors are rhythmic or alternating involuntary movements caused by the contraction of opposing muscle groups.

Myoclonus is a continual, rapid, short spasm involving a muscle, a part of a muscle, or even a group of muscles. Myoclonus frequently occurs in an extremity as the individual is falling asleep.

12. During the neurologic assessment, the nurse finds that a client is unable to calculate mathematical problems; however, the remainder of the assessment is normal. Which of the following does this finding suggest to the nurse?

The client may have an altered cognitive status.

The client could be depressed.

The client may have dementia.

The client may be nervous.

An inability to calculate simple problems may indicate the presence of organic brain disease, or it may simply indicate lack of exposure to mathematical concepts, nervousness, or an incomplete understanding of the examiner's language. In an otherwise unremarkable assessment, a poor response to calculations should not be considered an abnormal finding.

An inability to perform calculations may indicate altered cognitive status; however, the remainder of the assessment was normal.

Depression can have an effect on a client's ability to perform calculations; however, the remainder of the assessment was normal.

A client with dementia may exhibit difficulty in performing calculations; however, the remainder of the assessment was normal.

Explanation

An inability to calculate simple problems may indicate the presence of organic brain disease, or it may simply indicate lack of exposure to mathematical concepts, nervousness, or an incomplete understanding of the examiner's language. In an otherwise unremarkable assessment, a poor response to calculations should not be considered an abnormal finding.

An inability to perform calculations may indicate altered cognitive status; however, the remainder of the assessment was normal.

Depression can have an effect on a client's ability to perform calculations; however, the remainder of the assessment was normal.

A client with dementia may exhibit difficulty in performing calculations; however, the remainder of the assessment was normal.

13. When the nurse is interviewing the client, she knows that Parkinson's disease affects:

8–15% of adults over 65 years of age

15–21% of adults over 65 years of age

5–25% of adults over 55 years of age

9–17% of adults over 55 years of age

Based on Healthy People 2010, Parkinson’s disease occurs in 8–15% of adults over 65 years of age.

Explanation

Based on Healthy People 2010, Parkinson’s disease occurs in 8–15% of adults over 65 years of age.

14. During the neurologic assessment of a client the nurse would like to include questions to assess the client's ability to make health care decisions. Which tool can the nurse use to do this assessment?

Hopkins Competency Assessment

General Health Questionnaire

Mini-mental State Examination

Cornell Scale for Depression in Dementia

The Hopkins Competency Assessment assesses a person's ability to make decisions about health care.

The General Health Questionnaire provides assessment of emotional disturbance in those with normal cognitive ability.

The Mini-mental State Examination (MMSE) assesses cognitive status and is conducted during the client interview.

Behavioral problems are assessed using the Cornell Scale for Depression in Dementia.

Explanation

The Hopkins Competency Assessment assesses a person's ability to make decisions about health care.

The General Health Questionnaire provides assessment of emotional disturbance in those with normal cognitive ability.

The Mini-mental State Examination (MMSE) assesses cognitive status and is conducted during the client interview.

Behavioral problems are assessed using the Cornell Scale for Depression in Dementia.

15. A client with a head injury is demonstrating dysphagia and dysphasia. Which cranial nerve(s) might be involved with this symptom? Select all that apply.

Glossopharyngeal (CN IX)

Vagus (CN X)

Accessory (CN XI)

Facial (CN VII)

Trigeminal (CN V)

The glossopharyngeal nerve (CN IX) and the vagus nerve (CN X) are both involved in swallowing and speech. Damage to either of these cranial nerves can result in dysphagia (difficulty swallowing) and dysphasia (difficulty speaking). The glossopharyngeal nerve is responsible for sensory information from the back of the tongue and the pharynx, while the vagus nerve controls the muscles involved in swallowing and speech production. Damage to these nerves can disrupt the coordination and movement necessary for proper swallowing and speech. The other cranial nerves listed (Accessory, Facial, and Trigeminal) are not directly involved in swallowing and speech and would not typically cause these symptoms.

Explanation

The glossopharyngeal nerve (CN IX) and the vagus nerve (CN X) are both involved in swallowing and speech. Damage to either of these cranial nerves can result in dysphagia (difficulty swallowing) and dysphasia (difficulty speaking). The glossopharyngeal nerve is responsible for sensory information from the back of the tongue and the pharynx, while the vagus nerve controls the muscles involved in swallowing and speech production. Damage to these nerves can disrupt the coordination and movement necessary for proper swallowing and speech. The other cranial nerves listed (Accessory, Facial, and Trigeminal) are not directly involved in swallowing and speech and would not typically cause these symptoms.

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16. A client, seen previously for herpes zoster, comes into the clinic with ongoing neurologic changes, pain, and sensory/motor function changes. The nurse realizes that this client might be experiencing:

Myasthenia gravis

Lyme disease

Meningitis

Myelitis

Myelitis is an inflammation of the spinal cord. Herpes zoster infection is a common cause.

Myasthenia gravis is a chronic neuromuscular disorder involving increasing weakness of voluntary muscles with activity, and some abatement of symptoms with rest.

Lyme disease is an infection caused by a bite from an infected deer tick. Major symptoms include arthritis, a flulike syndrome and a rash.

Meningitis is caused by a virus or bacteria that infects the meninges of the brain or spinal cord. Headache, fever, and altered levels of consciousness can occur.

Explanation

Myelitis is an inflammation of the spinal cord. Herpes zoster infection is a common cause.

Myasthenia gravis is a chronic neuromuscular disorder involving increasing weakness of voluntary muscles with activity, and some abatement of symptoms with rest.

Lyme disease is an infection caused by a bite from an infected deer tick. Major symptoms include arthritis, a flulike syndrome and a rash.

Meningitis is caused by a virus or bacteria that infects the meninges of the brain or spinal cord. Headache, fever, and altered levels of consciousness can occur.

17. During the assessment of sensory function of a client, the nurse learns that the client has decreased pain sensation. Which of the following should the nurse document about this finding?

Anesthesia

Analgesia

Hypalgesia

Hypoesthesia

Hypalgesia is the term used for decreased pain sensation.

Analgesia is the absence of pain sensation.

Anesthesia is the inability to perceive the sense of touch.

Hypoesthesia is decreased, but not absent touch sensation.

Explanation

Hypalgesia is the term used for decreased pain sensation.

Analgesia is the absence of pain sensation.

Anesthesia is the inability to perceive the sense of touch.

Hypoesthesia is decreased, but not absent touch sensation.

18. When the nurse is explaining Parkinson's disease with the client, she explains that Parkinson's disease is a chronic disease with increasing weakness of voluntary muscles with activity and some abatement of symptoms

True

False

Parkinson’s disease is a degeneration of the basal nuclei of the brain, which are collections of nerve cells deep within the white matter of the cerebrum. These nuclei are responsible for initiating and stopping voluntary movement. Myasthenia gravis is a chronic neuromuscular disorder involving weakness of the voluntary muscles with activity.

Explanation

Parkinson’s disease is a degeneration of the basal nuclei of the brain, which are collections of nerve cells deep within the white matter of the cerebrum. These nuclei are responsible for initiating and stopping voluntary movement. Myasthenia gravis is a chronic neuromuscular disorder involving weakness of the voluntary muscles with activity.

19. The nurse is developing a community program to help prevent deaths from stroke. According to Healthy People 2020, which of the following actions should the nurse include in the program to prevent deaths from stroke? Select all that apply.

Education related to prevention

Education of the public about emergency response to symptoms

Screening for hypertension

Counseling about maintaining prescribed treatment for hypertension

Stroke treatment programs

Education related to prevention - Recommended to reduce stroke deaths.

Education of the public about emergency response to symptoms - Recommended to reduce stroke deaths.

Screening for hypertension - Recommended to reduce stroke deaths.

Counseling about maintaining prescribed treatment for hypertension - Recommended to reduce stroke deaths.

Stroke treatment programs - Not identified as an action to reduce stroke deaths.

Explanation

Education related to prevention - Recommended to reduce stroke deaths.

Education of the public about emergency response to symptoms - Recommended to reduce stroke deaths.

Screening for hypertension - Recommended to reduce stroke deaths.

Counseling about maintaining prescribed treatment for hypertension - Recommended to reduce stroke deaths.

Stroke treatment programs - Not identified as an action to reduce stroke deaths.

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