Exam 41: Assessing the Nervous System

An emergency department (ED) nurse receives a report that an incoming patient has a Glasgow Coma Scale (GCS) score of 8. Which is the most appropriate action by the nurse?

The nurse is preparing to assess a patient's cranial nerve XI (spinal accessory). What should the nurse ask the patient to complete this assessment?

The nurse is conducting a neurological assessment of a patient. Place an "X" on the technique the nurse should use to test for graphesthesia.

A patient in the supine position with the head flexed to the chest is not experiencing any pain, resistance, or flexion of the hips or knees. What is the nurse assessing in this patient?

The nurse observes signs that a patient may be experiencing dysfunction related to the acoustic nerve (CN VIII). Which actions should the nurse take to minimize the patient's risk for injury?

During an assessment of a patient's cranial nerves, the nurse states, "Please stick out your tongue." The nurse observes that the tongue deviates markedly to the right side. What is the patient most likely exhibiting?

The patient has lower motor neuron injuries. What type of reflexes should the nurse expect to assess in this patient?

The meal tray for a patient with damage to the glossopharyngeal nerve (CN IX) has been delivered. What action should the nurse take first?

A patient is exhibiting a lack of coordination, clumsy movements, and an unbalanced gait. What term should the nurse use when documenting these observations?

A patient experiencing extreme emotional stress is observed to be exhibiting both tachycardia and tachypnea. Which component of the patient's nervous system is responsible for normalizing the patient's response?

A patient is brought to the emergency department following a motor vehicle accident. The patient jerks away from the nurse attempting to start an IV in the right arm and says, "Bring me my book. I need to eat." When asked what happened in the accident, the patient looks frantically from nurse to nurse and says, "I have a dog." Calculate the patient's Glasgow Coma score. Record your answer rounding to the nearest whole number.

A patient reports hearing noises when alone in a quiet room. What action should the nurse take?

The nurse is preparing to assess a patient's cognitive function. What should the nurse include in this assessment?

The nurse understands that age-related changes in the neurological system include a decreased number of brain cells, decreased cerebral blood flow, and decreased metabolism. How would these expectations affect the nurse's plan when caring for an older patient at home?

The nurse asks a patient who has suffered a cerebral vascular accident (CVA) to complete the heel-to-shin test. What is the nurse testing for with this technique?

A patient is being evaluated for disease of the lower motor neurons. Which assessment findings should the nurse identify as consistent with this health problem?

The nurse asks the patient to walk heel-to-toe, on the toes, and then on the heels. What function is the nurse assessing?

To conduct the Romberg test, the nurse asks the patient to stand with the feet together and eyes closed. What must the nurse observe for the test to be considered normal?

A patient is in the hospital with suspected intracerebral hemorrhage. The nurse anticipates that which neurological test is likely to be ordered?

The nurse reads that a patient's reflexes are 3+. How should the nurse interpret this finding?