Question 1

When the nurse is testing the triceps reflex,what is the expected response?

Accepted Answer

The normal response is extension of the forearm.

Question 2

During the assessment of an 80-year-old patient,the nurse notes that his hands show tremors when he reaches for something and that his head is always nodding.There is no associated rigidity with movement.Which of the following statements is most accurate?

Accepted Answer

Senile tremors occasionally occur.These benign tremors include an intention tremor of the hands,head nodding (as if saying yes or no),and tongue protrusion.

Question 3

The nurse is testing the function of CN XI.Which of the following best describes the response the nurse would expect if the nerve is intact?

Accepted Answer

Examine the sternomastoid and trapezius muscles for equal size.Check equal strength by asking the person to rotate the head forcibly against resistance applied to the side of the chin.Then ask the person to shrug the shoulders against resistance.These movements should feel equally strong on both sides.

Question 4

During the neurological assessment of a "healthy" 35-year-old patient,the nurse asks him to relax his muscles completely.The nurse then moves each extremity through the full range of motion.Which of the following would the nurse expect to find?

Accepted Answer

Tone is the normal degree of tension (contraction)in voluntarily relaxed muscles.It shows a mild resistance to passive stretch.Normally,a mild,even resistance to movement will be noted.

Question 5

While assessing a 7-month-old infant,the nurse makes a loud noise and notes abduction and flexion of the arms and legs;fanning of the fingers,and curling of the index finger and thumb in a "C" position;and the infant bringing in its arms and legs toward its body.What does the nurse know about this response?

Accepted Answer

The Moro reflex is present at birth and disappears at 1 to 4 months.Absence of the Moro reflex in the newborn or persistence after 5 months of age indicates severe central nervous system injury.

Question 6

The nurse places a key in the hand of a patient,and he identifies it as a penny.What term would the nurse use to describe this finding?

Accepted Answer

Stereognosis is a person's ability to recognize objects by feeling their forms,sizes,and weights.Astereognosis is the inability to identify objects correctly and occurs with sensory cortex lesions.

Question 7

The nurse is testing the deep tendon reflexes of a 30-year-old woman during her annual physical examination.When striking the Achilles and quadriceps,the nurse is unable to elicit reflexes.The nurse's next response should be to:

Accepted Answer

Sometimes the reflex response fails to appear.Try further encouragement of relaxation,varying the person's position,or increasing the strength of the blow.Reinforcement is another technique to relax the muscles and enhance the response.Ask the person to perform an isometric exercise in a muscle group somewhat away from the one being tested.For example,to enhance a patellar reflex,ask the person to lock the fingers together and "pull."

Question 8

The assessment of a 60-year-old patient has taken longer than anticipated.In testing his pain perception,the nurse decides to complete the test as quickly as possible.When the nurse applies the sharp point of the pin to his arm several times,he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this?

Accepted Answer

Let at least 2 seconds elapse between each stimulus to avoid summation (frequent consecutive stimuli are perceived as one strong stimulus).

Question 9

Which of the following would the nurse use to test the motor coordination of an 11-month-old infant?

Accepted Answer

To screen gross and fine motor coordination,use the Nipissing District Developmental Screen test with its age-specific developmental milestones.

Question 10

In assessing a 70-year-old patient who has had a recent cerebrovascular accident,the nurse notes right-sided weakness.What might the nurse expect to find when testing his reflexes on the right side?

Accepted Answer

Hyperreflexia is the exaggerated reflex seen when the monosynaptic reflex arc is released from the influence of higher cortical levels.This occurs with upper motor neuron lesions (e.g. ,a cerebrovascular accident).

Question 11

To test for gross motor skill and coordination in a 6-year-old,which of the following techniques would be appropriate?

Accepted Answer

Normally the 4-year-old child can balance on one foot for about 5 seconds and the 5-year-old for 8 to 10 seconds;at 4 years of age the child can normally hop.Children enjoy performing these tests.Failure to hop after 5 years of age indicates incoordination of gross motor skill.

Question 12

The nurse is performing a neurological assessment for a 41-year-old woman with a history of diabetes.When testing her ability to feel the vibrations of a tuning fork,the nurse notes that the woman is unable to feel vibrations on the great toe or ankle bilaterally but is able to feel vibrations on both patellae.Given this information,what would the nurse suspect?

Accepted Answer

Loss of vibration sense occurs with peripheral neuropathy (e.g. ,diabetes and alcoholism).Peripheral neuropathy is worse at the feet and gradually improves with movement up the legs,as opposed to a specific nerve lesion,which has a clear zone of deficit for its dermatome.

Question 13

The nurse is testing superficial reflexes on an adult patient.When stroking up the lateral side of the sole and across the ball of the foot,the nurse notices the plantar flexion of the toes.How would the nurse document this finding?

Accepted Answer

With the same instrument,draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot,like an upside-down "J." The normal response is plantar flexion of the toes and sometimes of the whole foot.

Question 14

The nurse is doing an assessment on a 29-year-old woman who visits the clinic complaining of "always dropping things and falling down." While testing rapid alternating movements,the nurse notices that the woman is unable to pat both her knees.Her response is very slow,and she misses frequently.What might the nurse suspect?

Accepted Answer

In rapid,alternating movements,slow,clumsy,and sloppy response occurs with cerebellar disease.

Question 15

In the assessment of a 1-month-old infant,the nurse notes a lack of response to noise or stimulation.The mother reports that in the last week he has been sleeping most of the time,and when awake,all he does is cry.The nurse hears that the infant's cries are very high-pitched and shrill.What would be the nurse's appropriate response to these findings?

Accepted Answer

A high-pitched,shrill cry or feline screech occurs with central nervous system damage.Lethargy,hyporeactivity,hyperirritability,and the parent's report of significant change in behaviour all warrant referral.

Question 16

The nurse is taking the health history of a 78-year-old man.During the history,his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." In doing the assessment of his sensory system,the nurse would do which of the following?

Accepted Answer

Ensure the validity of sensory system testing by making sure the person is alert,cooperative,and comfortable,and has an adequate attention span.Otherwise,misleading and invalid results may occur.

Question 17

While the nurse is taking the health history of a 68-year-old patient who sustained a head injury 3 days earlier,he tells the nurse that he is on a cruise ship and is 30 years old.The nurse knows that this finding is indicative of:

Accepted Answer

A change in consciousness may be subtle.Note any decreasing level of consciousness,disorientation,memory loss,uncooperative behaviour,or even complacency in a previously combative person.

Question 18

To assess the head control of a 4-month-old infant,the nurse lifts the infant up in a prone position while supporting his chest.What normal response does the nurse look for?

Accepted Answer

At 3 months of age,the baby raises its head and arches its back,as if in a swan dive.This is the Landau reflex,which persists until 1½ years of age.

Question 19

When the nurse asks a 68-year-old patient to stand with his feet together,his arms at his sides,and his eyes closed,he starts to sway and moves his feet further apart.The nurse would document this finding as a(n):

Accepted Answer

Abnormal findings for the Romberg test include the patient swaying,falling,or widening the base of the feet to avoid falling.A positive Romberg sign is a loss of balance that is increased by closing the eyes.

Question 20

The nurse is caring for a patient who has just had neurosurgery.To assess for increased intracranial pressure,what would the nurse include in the assessment?

Accepted Answer

Some hospitalized persons have head trauma or a neurological deficit from a systemic disease process.These people must be monitored closely for any improvement or deterioration in neurological status,and for any indication of increasing intracranial pressure.Use an abbreviation of the neurological examination in the following sequence: level of consciousness,motor function,pupillary response,and vital signs.

Quiz 25: Neurological System