Neurological Assessment Case Study
Exam Questions And Answers
The nurse begins the admission assessment with the collection of
assessment data that is immediately entered into the electronic
health record (EHR).
When eliciting data about possible neurological problems, what
information should the nurse obtain from the client? (Select all that
apply. One, some, or all options may be correct.)
A. Any difficulty speaking or swallowing.
B. Ever hear voices that no one else hears.
C. Headache frequency and location.
D. Any numbness,tingling, or weakness of extremities.
E. Did the head hit the floor with syncopal episode - - - correct
answer ✅A, C, D, E
Speech or swallowing difficulties are changes that are associated
with an increased risk of stroke. Headaches can indicate
hypertension or intracranial bleeding. Sensory function is an
important component of a neurological assessment because loss of
sensation may indicate a stroke or neuropathy. Loss of
consciousness, confusion, and intracranial bleeding can occur as a
result of a head injury, so the nurse should determine whether the
client sustained a head injury. The nurse needs to examine the
,Neurological Assessment Case Study
Exam Questions And Answers
client for raccoon eyes or a battle sign to rule out a skull fracture.
Also, the nurse should note and report any drainage from eyes,
ears,and/or nose to make sure that it is not spinal fluid leaking.
Check for "halo sign" on bed linens, which could also indicate CSF
leakage.
Based on the client's recent history of loss of consciousness and
falling, what additional assessment takes priority?
A. Pedal pulse volume.
B. Deep tendon reflexes.
C. Two-point discrimination.
D. Blood pressure and heart rate and rhythm - - - correct answer
✅D. Blood pressure and heart rate and rhythm
Hypotension and bradycardia can cause a loss of consciousness.
Bradycardia may also be a sign of increased intracranial pressure.If
the client has hypertension, it places the client at increased risk for
a hemorrhagic stroke. If the client has cardiac irregularity, such as
atrial fibrillation, the client should be evaluated and treated to
prevent an embolic stroke.
, Neurological Assessment Case Study
Exam Questions And Answers
To determine what happened to the client prior to the loss of
consciousness, the nurse should obtain what information from the
client? (Select all that apply. One, some, or all options may be
correct.)
A. Ask the client to stick out their tongue.
B. Ask the client if they ever feel lightheaded or dizzy.
C. Ask the client if they have any problems with smell.
D. Ask the client if the dizziness occurs when they change positions.
E. Ask the client if they felt like the room was suddenly spinning
before the fell - - - correct answer ✅B, D, E
B - This could indicate poor cerebral perfusion due to hypotension
or carotid occlusion, which could cause loss of consciousness.
D - Postural hypotension occurs with position changes and may
cause a client to fall when moving from a lying to sitting position.
E - This indicates vertigo, which is related to alterations of vestibular
apparatus in the ear. If the nerve is damaged, the client may
experience equilibrium and balance issues.
Exam Questions And Answers
The nurse begins the admission assessment with the collection of
assessment data that is immediately entered into the electronic
health record (EHR).
When eliciting data about possible neurological problems, what
information should the nurse obtain from the client? (Select all that
apply. One, some, or all options may be correct.)
A. Any difficulty speaking or swallowing.
B. Ever hear voices that no one else hears.
C. Headache frequency and location.
D. Any numbness,tingling, or weakness of extremities.
E. Did the head hit the floor with syncopal episode - - - correct
answer ✅A, C, D, E
Speech or swallowing difficulties are changes that are associated
with an increased risk of stroke. Headaches can indicate
hypertension or intracranial bleeding. Sensory function is an
important component of a neurological assessment because loss of
sensation may indicate a stroke or neuropathy. Loss of
consciousness, confusion, and intracranial bleeding can occur as a
result of a head injury, so the nurse should determine whether the
client sustained a head injury. The nurse needs to examine the
,Neurological Assessment Case Study
Exam Questions And Answers
client for raccoon eyes or a battle sign to rule out a skull fracture.
Also, the nurse should note and report any drainage from eyes,
ears,and/or nose to make sure that it is not spinal fluid leaking.
Check for "halo sign" on bed linens, which could also indicate CSF
leakage.
Based on the client's recent history of loss of consciousness and
falling, what additional assessment takes priority?
A. Pedal pulse volume.
B. Deep tendon reflexes.
C. Two-point discrimination.
D. Blood pressure and heart rate and rhythm - - - correct answer
✅D. Blood pressure and heart rate and rhythm
Hypotension and bradycardia can cause a loss of consciousness.
Bradycardia may also be a sign of increased intracranial pressure.If
the client has hypertension, it places the client at increased risk for
a hemorrhagic stroke. If the client has cardiac irregularity, such as
atrial fibrillation, the client should be evaluated and treated to
prevent an embolic stroke.
, Neurological Assessment Case Study
Exam Questions And Answers
To determine what happened to the client prior to the loss of
consciousness, the nurse should obtain what information from the
client? (Select all that apply. One, some, or all options may be
correct.)
A. Ask the client to stick out their tongue.
B. Ask the client if they ever feel lightheaded or dizzy.
C. Ask the client if they have any problems with smell.
D. Ask the client if the dizziness occurs when they change positions.
E. Ask the client if they felt like the room was suddenly spinning
before the fell - - - correct answer ✅B, D, E
B - This could indicate poor cerebral perfusion due to hypotension
or carotid occlusion, which could cause loss of consciousness.
D - Postural hypotension occurs with position changes and may
cause a client to fall when moving from a lying to sitting position.
E - This indicates vertigo, which is related to alterations of vestibular
apparatus in the ear. If the nerve is damaged, the client may
experience equilibrium and balance issues.
