When the nurse is assessing the motor function of cranial nerve VII as part of the neurological examination What should the nurse instruct the client to do quizlet?

a. VIII
Explanation:
Cranial nerve VIII contains sensory fibers for hearing and balance.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 571.
Chapter 25: Assessing Neurologic System - Page 571

b. Instruct the client to flex and extend the right elbow
Explanation:
Instructing the client to flex and extend the right elbow is assessing strength, which is a part of the motor system assessment. Instructing the client to state the current date and place is part of the mental status assessment. Instructing the client to smile and close the eyes is part of the cranial nerve assessment.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 579.
Chapter 25: Assessing Neurologic System - Page 579

a. Client stands erect with minimal swaying
Explanation:
The Romberg test is negative is the client stand erect with minimal swaying with eyes both opened and closed. Balance when walking is not part of the Romberg test.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 587.
Chapter 25: Assessing Neurologic System - Page 587

a. Swaying
Explanation:
A positive Romberg test is when the client sways and moves the feet apart to prevent falling. The Romberg test is not used to assess gait, hand grasps, or the brachial reflex.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 587.
Chapter 25: Assessing Neurologic System - Page 587

b. Temporal lobe herniation
Explanation:
A pupil that is fixed and dilated can indicate herniation of the temporal lobe that causes compression of the oculomotor nerve and midbrain. Pupils that are large and reactive are seen in cocaine or other sympathetic nervous system agonist drugs. Pupils that are fixed in mid-position indicate structural damage in the midbrain. Small or pinpoint pupils indicate damage to the sympathetic pathways in the hypothalamus.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 582.
Chapter 25: Assessing Neurologic System - Page 582

c. Absence
Explanation:
This is a common description and scenario for absence seizures, which are generally brief (fewer than 10 seconds, "petit mal"). They generally occur without warning and do not have a post-ictal confused state. Pseudoseizures are difficult to diagnose but generally involve dramatic-appearing movements, similar to tonic-clonic seizures. Myoclonus represents a single brief jerk of the trunk and limbs.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 573.
Chapter 25: Assessing Neurologic System - Page 573

b. Dorsiflexion of the great toe and fanning of all toes
Explanation:
An injury to the spinal cord or the brain causes abnormal posturing in the client. This includes dorsiflexion of the great toe and fanning of all toes when the sole of the foot is stroked—a positive Babinski reflex—which is normal in newborns but in adults is an indication of lesions of upper motor neurons or unconscious states resulting from drug and alcohol intoxication, brain injury, or subsequent to an epileptic seizure. In the normal adult, the response to stroking the bottom of the foot is flexion of the toes. Dorsiflexion and plantar flexion are not associated with this reflex.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 595.
Chapter 25: Assessing Neurologic System - Page 595

a. Decreased sensation in the feet
Explanation:
A client with peripheral neuropathy would have decreased sensation in extremities. Pain, discoloration, and open sores would not be expected.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 590.
Chapter 25: Assessing Neurologic System - Page 590

d. Glasgow
Explanation:
An appropriate scale to assess the neurological status of an unconscious client is the Glasgow Coma Scale (GCS). The Norton and Braden scales are used to assess skin. The Morse Fall scale is used to assess the risk for falls.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 579.
Chapter 25: Assessing Neurologic System - Page 579

d. Cerebellar ataxia
Explanation:
A wide-based, staggering, unsteady gait and positive Romberg test (client unable to stand with feet together) suggest cerebellar ataxia. Spastic hemiparesis is characterized by a flexed arm held close to the body while the client drags the toes of the leg or circles it stiffly outward and forward. A Parkinsonian gait is a shuffling gait. A scissors gait is a short stiff gait with the thighs overlapping each other with each step.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 603.
Chapter 25: Assessing Neurologic System - Page 603

a. "Walk across the room and back."
Explanation:
It is important to ask the client to walk across the room and walk back first because this will reveal deficits in the gait. This, in turn, will allow the nurse to focus the assessment. Asking the client to walk across the room and then back assists the nurse in observing posture, balance, swinging of the arms, and movements of the legs. Asking the client to walk heel to toe is called "tandem walking." It would be appropriate to instruct the client to do this to determine if there is ataxia that was not previously obvious. Asking the client to walk on the toes then on the heels assists the nurse in assessing for plantar flexion of the ankles as well as for balance. The nurse should instruct the client to do this if problems with balance are noted initially. Asking the client to hop in place provides information about the client's position sense and cerebellar function. If the nurse is not yet aware whether the client is at risk for falls, this assessment should be left until the quality of gait has been assessed.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 587.
Chapter 25: Assessing Neurologic System - Page 587

a. Increase reflex activity
Explanation:
The client is performing the technique of reinforcement. It works if the client's reflexes are absent by using isometric contraction of other muscles to increase reflex activity. This action is not being done to keep the knee in position. It does not help with focus on the hammer when striking the knee. This is not the position to assess the arm reflexes.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 594.
Chapter 25: Assessing Neurologic System - Page 594

a. Hypothalamus
Explanation:
The hypothalamus controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions. It maintains overall autonomic control. The medulla, part of the brain stem, controls the cardiac, respiratory, vomiting, and vasomotor centers, dealing with autonomic (involuntary) functions of breathing, blood pressure, and heart rate. The brain stem also contains the pons and midbrain. The cerebral cortex is the covering of the cerebrum. Its role is in memory, attention, and consciousness.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 569.
Chapter 25: Assessing Neurologic System - Page 569

When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence?

a.Cranial nerves, motor/cerebellar, sensory, reflexes, mental status
b.Motor/cerebellar, sensory, reflexes, cranial nerves, mental status
c.Reflexes, sensory, motor/cerebellar, cranial nerves, mental status
d.Mental status, cranial nerves, motor/cerebellar, sensory, reflexes

d. Mental status, cranial nerves, motor/cerebellar, sensory, reflexes
Explanation:
The nurse should perform the assessment of the nervous system from a level of higher cerebral integration to a level of lower reflexes.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 576.
Chapter 25: Assessing Neurologic System - Page 576

d. Whisper, Rinne, and Weber tests
Explanation:
Cranial nerve VIII is the acoustic/vestibulocochlear nerve, which is associated with the client's ability to hear. The nurse should perform the whisper test and, using the tuning fork, the Rinne and Weber tests. The gag reflex, rise of the uvula, and ability to swallow are tests to assess cranial nerves IX (glossopharyngeal) and X (vagus). Asking the client to smile, frown, show teeth, and puff out the cheeks assesses the function of cranial nerve VII (facial). Clenching the teeth, identifying light touch, and discriminating between sharp and dull stimuli are assessments of cranial nerve V (trigeminal).
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 584.
Chapter 25: Assessing Neurologic System - Page 584

b. Oculomotor
Explanation:
The oculomotor nerve causes pupillary constriction, opening the eye (lid elevation), and most extraocular movements.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 571.
Chapter 25: Assessing Neurologic System - Page 571

b. 68-year-old African American male with hypertension
Explanation:
Risk factors include older adulthood (risk doubling each decade after age 55), male sex, African American race, hypertension, smoking, chronic alcohol intake (more than three drinks per day), and sleep apnea among others. In the clients listed, the 68-year-old African American male with hypertension has the greatest risk due to his age, race, and hypertension. The other clients would be at risk, but the risk would be less.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 578.
Chapter 25: Assessing Neurologic System - Page 578

c. Broca's area
Explanation:
The Broca's area is the center that is responsible for speech. The temporal lobe helps with receiving and interpreting impulses from the ear. The occipital lobe influences the ability to read with understanding and is the primary visual receptor center. The medulla oblongata contains the nuclei for the cranial nerves and has centers that control and regulate respiratory function, heart rate and force, and blood pressure.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.

-mental status
-cranial nerves
-motor system
-sensory system
-reflexes
Explanation:
A complete neurologic examination consists of evaluating the following five areas: mental status, cranial nerves, motor and cerebellar systems, sensory system, and reflexes.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 576.
Chapter 25: Assessing Neurologic System - Page 576

b. Communication
Explanation:
Assessment of the frontal lobe is done by testing the client's communication. To assess the function of the parietal lobe, the nurse should test for tactile sensation. The function of the temporal lobe is assessed by testing for impulses from the ear. To assess the function of the occipital lobe, the nurse should test the ability to read.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 568.
Chapter 25: Assessing Neurologic System - Page 568

a. shrug shoulders against resistance
Explanation:
The function of cranial nerve XI can be assessed by asking the client to shrug his or her shoulders against resistance. Asking the client to move the tongue from side to side assesses function of the hypoglossal nerve, Cranial nerve XII. The nurse asks the client to swallow water to assess the function of cranial nerves IX and X. Asking the client to walk in heel-to-toe fashion helps in assessment of balance.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 585.
Chapter 25: Assessing Neurologic System - Page 585

b. Right knee +2; Left knee +1
Explanation:
A normal reflex response is documented as being +2. A diminished reflex response is documented as being +1. A 0 is no reflex response. A +3 is a brisker than average response. A +4 is a very brisk response.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 580.
Chapter 25: Assessing Neurologic System - Page 580

d. Intentional tremor
Explanation:
Older adults may experience intentional tremors (tremors that occur with intentional movements). This may be seen with extending the hands, head nodding for "yes or no," or extending one's tongue, which may protrude back and forth. Such tremors are not associated with disease, but they may cause embarrassment or emotional distress. Fasciculations and atrophy of the tongue may be seen with peripheral nerve disease. Injury of the central spinal cord is associated with extremity weakness. Sudden numbness and weakness of the muscles of the face, arms, and legs are associated with cerebrovascular accident (stroke).
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 575.
Chapter 25: Assessing Neurologic System - Page 575

d. glossopharyngeal.
Explanation:
The glossopharyngeal nerve contains sensory fibers for taste on posterior third of tongue and sensory fibers of the pharynx that result in the gag reflex when stimulated.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 571.
Chapter 25: Assessing Neurologic System - Page 571

a. "Can you tell me where you are right now?"
Explanation:
The nurse should only assess for orientation to date and place when conducting a mental status assessment as part of the neurological examination. Asking details about mood, history of psychiatric disorders, and fluctuations in emotions is better placed when conducting a full mental status assessment, not as part of the screening neurological assessment.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 576,579.
Chapter 25: Assessing Neurologic System - Page 576,579

c. Document the findings.
Explanation:

A GCS score of 15 is the maximum score indicating the client's neurological status is normal. Therefore, the nurse should document the findings. This information makes all the remaining options incorrect.

Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 597, 579.
Chapter 25: Assessing Neurologic System - Page 597, 579

a. Cerebellar disease
Explanation:
In cerebellar disease, movements are clumsy, unsteady, and inappropriately varying in their speed, force, and direction. The finger may initially overshoot its mark, but finally reaches it fairly well, termed dysmetria. An intention tremor may appear toward the end of the movement.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 603.
Chapter 25: Assessing Neurologic System - Page 603

c. Dysarthria
Explanation:
Deficits in articulation are referred to as dysarthria.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 574.
Chapter 25: Assessing Neurologic System - Page 574

a. Smile.
Explanation:
Cranial nerve VII is the facial cranial nerve and is responsible for facial movements such as facial expressions. Clenching the teeth is associated with cranial nerve V, the trigeminal nerve. The nurse should instruct the client to cover one eye if assessing cranial nerves III, IV, and VI otherwise, oculomotor, trochlear, abducens, respectively. Smelling coffee beans would assist in assessing cranial nerve I, the olfactory nerve.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 583.
Chapter 25: Assessing Neurologic System - Page 583

-True
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 589.
Chapter 25: Assessing Neurologic System - Page 589

a. Cerebellar ataxia
Explanation:
Cerebellar ataxia is recognized by the wide-based and staggering gait. The Romberg test will be positive. This gait can be seen in persons with cerebellar disease or alcohol or drug intoxication. The characteristic abnormality in Parkinson's disease is the shuffling gait with a stooped-over posture and flexion of the hips and knees. Spastic hemiparesis presents with the arm flexed and held close to the body while the client drags the toes and circles the leg outward and forward. Foot drop is seen when the client lifts the foot and knee high with each step, then slaps the foot hard to the ground.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 603.
Chapter 25: Assessing Neurologic System - Page 603

d. "Can you repeat brown, chair, textbook, tomato?"
Explanation:
Remote memory (past dates and historical accounts) may be impaired in cerebral cortex disorders.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.

d. parasympathetic
Explanation:
The parasympathetic nervous system conserves energy and resources during times of rest and relaxation. The central nervous system consists of the brain and spinal cord. The sympathetic nervous system mobilizes organs and their functions during times of stress and arousal. The cranial nerves emerge from within the cranial vault through skull foramina and canals to structures in the head and neck.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 572.
Chapter 25: Assessing Neurologic System - Page 572

a. Delirium
Explanation:
Delirium in an acute onset of confusion related to an underlying cause such as medication, disease or traumatic event. Dementia occurs over a time, amnesia is a loss of memory and hypoxia may be a cause of delirium.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 575.
Chapter 25: Assessing Neurologic System - Page 575

a. Slow speech with appropriate meaning
Explanation:
The client diagnosed with right side hemiplegia and expressive aphasia can verbally state wishes. Expressive aphasia is also called Broca's aphasia in which the speech is slowed with difficult articulation but fairly clear meaning. Clients with Wernicke's aphasia have rapid speech with no meaning. Inability to recognize familiar objects is called agnosia. Trouble remembering familiar faces is termed prosopagnosia. Both of these conditions can occur with damage to the temporal and occipital lobes of the brain.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 598.
Chapter 25: Assessing Neurologic System - Page 598

d. Cerebellar ataxia
Explanation:
Cerebellar ataxia, a wide-based gait with staggering and lurching, is often due to alcohol intake or cerebral palsy. Spastic hemiparesis is usually caused by stroke, not alcohol intoxication. Scissors gait is spastic diplegia associated with bilateral spasticity of the legs. Sensory ataxia is due to cerebral palsy also resulting in a wide-based gait.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 603.
Chapter 25: Assessing Neurologic System - Page 603

d. thalamus and hypothalamus.
Explanation:
The diencephalon lies beneath the cerebral hemispheres and consists of the thalamus and hypothalamus.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 569.
Chapter 25: Assessing Neurologic System - Page 569

a. Pain and light touch
Explanation:
The sensory aspects of CN V are assessed for by testing pain sensation (confirmed by temperature sensation) and light touch.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 571, 582.
Chapter 25: Assessing Neurologic System - Page 571, 582

-Difficulty following instructions
-Slurred speech
-Impaired vision
Explanation:
Signs and symptoms of a stroke that would be found during a neurological assessment include difficulty following instructions, slurred speech and impaired vision. The client may or may not be oriented x 3 and the nurse would expect to find the client hypertensive.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 577.
Chapter 25: Assessing Neurologic System - Page 577

c. sympathetic nervous system
Explanation:
The sympathetic nervous system mobilizes organs and their functions during times of stress and arousal such as with the experience of anxiety. The peripheral nervous system supplies nerve stimulation to the heart, visceral organs, skin, and the extremities. The autonomic nervous system connects to internal organs and generates autonomic reflex responses. The somatic nervous system regulates muscle movements and response to sensations of touch and pain.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 572.
Chapter 25: Assessing Neurologic System - Page 572

c. Steppage gait
Explanation:
Steppage gait is associated with foot drop, usually secondary to a lower motor neuron disease. This is often seen with a herniated disc.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 603.
Chapter 25: Assessing Neurologic System - Page 603

b. Clonus
Explanation:
Clonus is a sustained rhythmical "beating" that correlates with CNS disease and hyperreflexia. A focal seizure could be virtually ruled out by stopping the stimulus and watching the phenomenon stop. Extinction is a term applied to sensory testing in which one side of a simultaneous, bilateral stimulus is not felt because of damage to the cortex. Reinforcement applies to enhancing reflex examination by distracting the client (e.g., pulling his hands against each other).
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 580.
Chapter 25: Assessing Neurologic System - Page 580

a. Impulses from the ear
Explanation:
The function of the temporal lobe is assessed by testing for impulses from the ear. To assess the function of the parietal lobe, the nurse should test for tactile sensation. Assessment of the frontal lobe is done by testing the client's communication. To assess the function of the occipital lobe, the nurse should test the ability to read.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 568.
Chapter 25: Assessing Neurologic System - Page 568

c. Determine the ability to differentiate hot and cold temperatures
Explanation:
If a client cannot correctly differentiate between sharp and dull pain sensations, the nurse should test for temperature sensation. Temperature and pain sensations travel in the lateral spinothalamic tract, thus temperature is only tested if pain sensation is altered. If a client cannot feel pain, feeling a lighter touch is unlikely. Striking a tuning fork and placing it on the top of one foot tests vibratory sensation, not pain or touch. The nurse should not try another object and test on the upper dermatomes, as this would not likely change the results.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 590.
Chapter 25: Assessing Neurologic System - Page 590

c. spinothalamic tract.
Explanation:
Sensations of pain, temperature, and crude and light touch travel by way of the spinothalamic tract.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 569.
Chapter 25: Assessing Neurologic System - Page 569

c. Psychiatric medications
Explanation:
Dystonia is commonly due to the use of psychiatric medications, resulting in slow, involuntary movement of the trunk and larger muscles. These movements may also be accompanied by twisted postures.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.

b. sensory
Explanation:
The nurse performed stereognosis which is a technique used to assess the sensory status. Assessment of the motor status includes gait, muscle strength, and muscle tone. Position sense determines if the client has intact proprioception. Responsiveness refers to level of consciousness.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 583.
Chapter 25: Assessing Neurologic System - Page 583

d. Pain and hip flexion when the neck is flexed
Explanation:
Pain and flexion of the hips and knees is a positive Brudzinski sign that suggests meningeal inflammation. If the hips and knees remain relaxed and the neck is able to be flexed to the chest, the client is not demonstrating signs of meningeal irritation. Pain behind the knees when fully extended is a normal finding in some people.
Reference:
Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 25: Assessing Neurologic System, p. 596.
Chapter 25: Assessing Neurologic System - Page 596

What should the nurse instruct the patient to do to assess the motor function of cranial nerve VII?

Cranial Nerve VII – Facial Nerve Test motor function. Ask the patient to smile, show teeth, close both eyes, puff cheeks, frown, and raise eyebrows. Look for symmetry and strength of facial muscles.

Which facial movements are expected on assessment of the facial nerve CN VII )?

Left sided forehead wrinkle, left eyelid closure, and movement of the left half of the face is stimulated by the left 7th cranial nerve. Lacrimation (tearing) and salivation are also stimulated by the 7th cranial nerve.

Which tests are appropriate for a nurse to perform cranial nerve VIII quizlet?

Which tests are appropriate for a nurse to perform to test the cranial nerve VIII? Cranial nerve VIII is the acoustic/vestibulocochlear which assesses the client's ability to hear. The nurse should perform the whisper test, and the Rinne and Weber test using the tuning fork.

Why is the facial VII nerve considered the major motor nerve of the head quizlet?

The facial nerve is considered the major motor nerve of the head because it innervates more named muscles than any other nerve in the body. The vestibular branch of the vestibulocochlear nerve functions in hearing while the cochlear branch is involved in equilibrium.