Neurological Assessment Case Study Exam Questions and Answers

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 - Ans:-A, C, D, E ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 2/20 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 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 - Ans:-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 ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 3/20 hemorrhagic stroke. If the client has cardiac irregularity, such as atrial fibrillation, the client should be evaluated and treated to prevent an embolic stroke. 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 - Ans:-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. ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 4/20 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. During the interview, the nurse observes the client's speech patterns. The client seems to have difficulty choosing and forming some words. What action should the nurse take? A. Affirm the client's difficulty and ask about when this first started. B. Fill in the conversation with the words the client is attempting to say. C. Offer to complete the interview at a later time after the client has rested. D. Allow the client to respond and ignore any difficulty to avoid embarrassment - Ans:-A. Affirm the client's difficulty and ask about when this first started. This action demonstrates caring and also enables the nurse to obtain a more complete history related to the onset of the client's symptoms. Before continuing the interview and assessment, the nurse enters the following initial data collected into a tablet: The client demonstrates difficulty speaking and previously reported feeling weak, passing out, ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 5/20 and falling at home. Vital signs are currently T 97° F (36o C), Blood Pressure 140/88 mmHg, heart rate 92beats/min, and respirations 18 breaths/min. What terminology should be included in the nurse's documentation? A. Dysphagia. B. Tachycardia. C. Syncope. D. Paresis - Ans:-C. Syncope. Syncope is a sudden loss of strength or temporary loss of consciousness, which the client described as "passing out." In documenting the client's difficulty speaking, the nurse recalls th