Neuromuscular

The nurse should be aware that which of the following factors has the greatest effect on the symptoms seen following a stroke?

• The area of the brain affected.

• How long before the patient sought treatment.

• Whether it was ischemic or hemorrhagic.

• The patient’s previous medical history.

The nurse is assessing an adult client who has suffered a head injury. During the assessment, when the nurse touches the client’s lips, he begins to suck (a primitive reflex). How should the nurse interpret this response?

• This indicates damage to the neurologic system

• This is an expected response in this client

• This indicates that the client is hungry

• This indicates that the client is healing appropriately

The nurse is caring for a client who has a long history of type 2 diabetes mellitus (T2DM) and peripheral neuropathy. What is the priority assessment for this client?

• Ensuring the airway is patent

• Examination of the nails for clubbing

• Examination of the feet for ulcers

• Examination of the client’s level of consciousness

The nurse is caring for a client who has been admitted due to a CVA. Which of the following should the nurse recognize as possible signs of a CVA? Select all that apply.

• Lumbar pain

• Confusion

• Headache

• Blurred vision

While assessing a client, the nurse notes the absence of a gag reflex. Which cranial nerve may not be functioning properly?

• CN I (1-Oflactory)

• CN IV (4-Trochlear)

• CN X (10-Vagus)

• CN XII (12-Hypoglossal)

Which of the following applies to the client in the previous question?

• Risk for injury related to falls

• Risk for aspiration

• Anxiety related to hospitalization

• Imbalanced nutrition: More than body requirements

While assessing a client, the nurse notices that the client does not respond to verbal commands. What is a possible cause of this finding?

• There is a problem with CN XI (11-Spinal Accessory)

• There is a problem with CN V (5-Trigeminal)

• There is a problem with CN II (2-Optic)

• There is a problem with CN VIII (8-Acoustic)

When testing muscle strength, a client has difficulty moving each extremity against resistance. Which of the following should the nurse do next?

• Move the part passively through its range of motion.

• Ask the client to move the part against gravity.

• Inspect by touch for a palpable contraction of the muscle.

• Document the findings and proceed to the next body system's assessment.

Assessment reveals that a client has slight weakness with active range of motion against some resistance. The nurse would document this as which of the following?

• 2/5

• 3/5

• 4/5

• 5/5

The nurse is caring for a client who has a suspected head injury. When asked to administer eye drops to dilate the client's pupils for the eye exam, how should the nurse respond?

• Administer the drops as prescribed

• Tell the provider that you do not think this is an appropriate action

• Administer half of the prescribed dose

• Tell the provider that you will perform the eye exam and report the findings