Neurologic and Mental Status Assessment

The nurse performs a BP screening at the local community center. As part of the health promotion intervention, the nurse also discusses the following risk factors for stroke:

• Low BP, lack of exercise, and diet high in fat

• High BP, diet high in fat, and smoking

• Diet high in fat, smoking, and walking five times weekly

• Obesity, swimming five times weekly, high BP

Answer explanation

A health history of diabetes mellitus, carotid artery disease, atrial fibrillation, and sickle cell disease places a person at risk for neurovascular disease. Additionally, lifestyle choices of smoking, a high-fat diet, obesity, and physical inactivity increase the person's risk for stroke.

The use of the GCS provides a relatively objective assessment of LOC. The three functions assessed are:

• pupil reaction, orientation, and sensation

• verbal response, eye opening, and motor response

• eye opening, motor response, and sensation

• verbal response, pupil response, and motor response

Answer explanation

The GCS includes verbal response, eye opening, and motor response but does not include pupillary response and sensation. Abnormalities of the pupil reaction are associated with altered consciousness but may also result from peripheral nerve injury. Sensation cannot be assessed accurately if the patient has any difficulty with communication.

The chart states that a 62-year-old person has had a stroke in the right parietal area of the brain. The nurse expects to note which of the following?

• Tremors on the left side of the face.

• Tremors on the right side of the face.

• Weakness in the right arm.

• Weakness in the left arm.

Answer explanation

Weakness results from loss of motor function in the motor cortex of the brain. Tremors are associated with other diseases (e.g. Parkinson's disease and multiple sclerosis). The deficit is on the opposite side of the body because the motor fibers cross, causing left-sided weakness.

A 47-year-old patient states that they are having vertigo and some difficulty with balance. The nurse should assess:

• accommodation

• the whisper test

• shoulder strength

• soft touch

Answer explanation

Balance and equilibrium are associated with CN VIII. Performing a whisper test will evaluate hearing, also associated with CN VIII. Testing for accommodation evaluates CN III. Shoulder shrug assesses CN XI, and soft-touch assesses CN V.

A patient in a nursing home was admitted with a diagnosis of dementia. They started a fire because they were cooking at home and forgot they had left a pan on the stove. The nursing diagnosis that is of the highest priority is:

• ineffective brain tissue perfusion

• risk for injury

• acute confusion

• impaired memory

Answer explanation

Safety assumes priority because of the risk for injury. Impaired memory is also a likely diagnosis because of his forgetfulness. No data exist about confusion, so that is an area that needs further assessment. Ineffective brain perfusion is associated more with stroke.