CHAPTER 60: ASSESSMENT OF NEUROLOGIC FUNCTION

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1. A nurse is performing a neuro- ANS: C

logical assessment on a client Rationale: The frontal lobe is the largest lobe located in front
at home. During the of the brain. It is responsible
assessment, the nurse notices in large part for a person's affect, judgment, personality, and
that the client has a flat affect. inhibitions. The parietal
Which lobe of the brain is lobe is essential to a person's awareness of body position in
responsible for a person's af- space, size and shape
fect? discrimination, and right-left orientation. The temporal lobe
A. Parietal lobe plays a role in memory of
B. Temporal lobe sound and understanding of language and music. The occip-
C. Frontal lobe ital lobe is responsible for
D. Occipital lobe visual interpretation and memory.

2. A client scheduled for magnet- ANS: B

ic resonance imaging (MRI) has Rationale: Client preparation for an MRI consists of removing
arrived at the radiology all metal-containing objects
department. The nurse who prior to the examination. Withholding stimulants would not
prepares the client for the MRI affect an MRI; this relates to
should prioritize what action? an electroencephalography (EEG). Instructing the client to
A. Withholding stimulants 24 to void is client preparation for a
48 hours prior to exam lumbar puncture. Initiating an IV line for administration of
B. Removing all metal-contain- contrast would be done if the
ing objects client was having a CT scan with contrast.
C. Instructing the client to void
prior to the MRI
D. Initiating an IV line for ad-
ministration of contrast

3. A gerontologic nurse planning ANS: B

the neurologic assessment of Rationale: Reduction in cerebral blood flow (CBF) is a change
an older adult is that occurs in the normal
considering normal, age-relat- aging process. Deep tendon reflexes can be decreased or, in
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ed changes that may influence some cases, absent.

the assessment results. Of Cerebral metabolism decreases as the client advances in age.
what phenomenon should the Reaction to painful stimuli
nurse be aware? may be decreased with age. Because pain is an important
A. Hyperactive deep tendon re- warning signal, caution must
flexes be used when hot or cold packs are used.
B. Reduction in cerebral blood
flow
C. Increased cerebral metabo-
lism
D. Hypersensitivity to painful
stimuli

4. A nurse is performing a com- ANS: B

plex neurological assessment Rationale: When assessing written and spoken language
on a client recently ability, clients are usually asked
diagnosed with Alzheimer dis- to read a newspaper article and explain the meaning. Clients
ease. What question should the are also asked to write their
nurse anticipate to ask name or copy a simple figure drawn by the examiner. Com-
when assessing the client's lan- parison questions are
guage ability? associated with assessing a client's intellectual function. Ask-
A. "How are a pencil and pen ing about the year and
alike?" current name of the president are associated with assessing
B. "Can you write your name on a client's mental status.
this blank sheet of paper?"
C. "Can you tell me what year it
is?"
D. "What is the name of the
president of the United States?"

5. A nurse is assessing reflexes in ANS: C

a client with hyperactive reflex- Rationale: When reflexes are very hyperactive, a phenomenon
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es. When the client's called clonus may be

foot is abruptly dorsiflexed, it elicited. If the foot is abruptly dorsiflexed, it may continue to
continues to "beat" two to three "beat" two to three times
times before settling into before it settles into a position of rest. Rigidity is an increase
a resting position. How should in muscle tone at rest
the nurse document this find- characterized by increased resistance to passive stretch. Flac-
ing? cidity is lack of muscle tone.
A. Rigidity Ataxia is the inability to coordinate muscle movements, result-
B. Flaccidity ing in difficulty walking,
C. Clonus talking, and performing self-care activities.
D. Ataxia

6. The nurse is doing an initial as- ANS: B

sessment on a client newly ad- Rationale: Difficulty copying a figure that the nurse has drawn
mitted to the unit with a would be considered visual
diagnosis of cerebrovascular receptive aphasia, which involves the parietal-occipital area.
disease. The client has difficulty Expressive aphasia, the
copying a figure that the inability to express oneself, is often associated with damage
nurse has drawn and is di- to the frontal area.
agnosed with visual receptive Receptive aphasia, the inability to understand what someone
aphasia. What brain region is else is saying, is often
primarily involved in this associated with damage to the temporal lobe area.
client's deficit?
A. Temporal lobe
B. Parietal-occipital area
C. Inferior-posterior frontal ar-
eas
D. Posterior frontal area

7. What term is used to describe ANS: D

the fibrous connective tissue Rationale: The term "meninges" describes the fibrous con-
that hugs the brain closely nective tissue that covers the
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and extends into every fold of brain and spinal cord. The meninges have three layers: the
the brain's surface? dura mater, arachnoid, and
A. Dura mater pia mater. The pia mater is the innermost membrane that
B. Arachnoid hugs the brain closely and
C. Fascia extends into every fold of the brain's surface. The dura mater,
D. Pia mater the outermost layer,
covers the brain and spinal cord. The arachnoid, the middle
membrane, is responsible for
the production of cerebrospinal fluid. This is not known as
"fascia."

8. The nurse is caring for a client ANS: C

with an upper motor neuron le- Rationale: Upper motor neuron lesions do not cause muscle
sion. What clinical atrophy, flaccid paralysis, or
manifestations should the slow reflexes. However, upper motor neuron lesions normally
nurse anticipate when planning cause loss of voluntary
the client's neurologic control.
assessment?
A. Decreased muscle tone
B. Flaccid paralysis
C. Loss of voluntary control of
movement
D. Slow reflexes

9. The nurse is admitting a client ANS: D

to the unit who is diagnosed Rationale: Lower motor neuron lesions cause flaccid muscle
with a lower motor neuron paralysis, muscle atrophy,
lesion. What entry in the client's decreased muscle tone, and loss of voluntary control.
electronic record is most con-
sistent with this diagnosis?
A. "Client exhibits increased
muscle tone."
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B. "Client demonstrates normal

muscle structure with no evi-
dence of atrophy."
C. "Client demonstrates hyper-
active deep tendon reflexes."
D. "Client demonstrates an ab-
sence of deep tendon reflexes."

10. An older adult client is being ANS: D

discharged home. The client Rationale: The sense of smell deteriorates with age. The ol-
lives alone and has atrophy factory organs are responsible
of the olfactory organs. The for smell. This may present a safety hazard for the client
nurse tells the client's family because he or she may not smell
that it is essential that the client smoke or gas leaks. Smoke detectors are universally neces-
have what installed in the sary, but especially for this
home? client.
A. Grab bars
B. Nonslip mats
C. Baseboard heaters
D. A smoke detector

11. The nurse is conducting a fo- ANS: D

cused neurologic assessment Rationale: The gag reflex is elicited by gently touching the
and is assessing the client's back of the pharynx with a
gag reflex. How should the cotton-tipped applicator, first on one side of the uvula and
nurse best perform this aspect then the other. The gag reflex
of the assessment? is not assessed by having the client swallow or by depressing
A. Depress the client's tongue the tongue.
with a sterile tongue depres-
sor.
B. Ask the client to swallow a
small quantity of any soft food.
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C. Observe the client swallow-

ing a small mouthful of water.
D. Lightly touch the client's
pharynx with a cotton swab.

12. When assessing a 36-year-old ANS: A

male, the nurse gently strokes Rationale: Reflexes are classified either as pathological, su-
the client's right palm perficial, or deep tendon.
using a cotton applicator. As the Pathological reflexes often represent the emergence of ear-
nurse strokes the client's palm lier reflexes that disappeared
the nurse then checks to with the maturity of the nervous system. The palmar reflex is
see if the client will begin to associated with assessing
grasp the applicator. This as- for a pathologic reflex. Superficial and deep tendon reflexes
sessment is associated with are not assessed using this
which of the following reflex- type of test. Brachioradialis is a type of deep tendon reflex.
es? Reflex tests are performed as
A. Pathologic a part of neurological assessment to quickly determine an
B. Superficial intact spinal cord.
C. Deep tendon
D. Brachioradialis

13. A 26-year-old female client, ANS: D

who is breastfeeding a new- Rationale: Breastfeeding women are instructed by the nuclear
born, is due to undergo a medicine department to
computed tomography (CT) stop for a certain time period when undergoing nuclear med-
scan with dye contrast. What in- icine/CT scan treatment.
struction should the nurse Clients are assessed to see if an allergy to shellfish/iodine
provide to the client based on exists prior to the procedure.
this procedure? Clients are encouraged to drink plenty of fluids after the
A. "Do not breastfeed your baby procedure to help the kidneys
for two weeks after the proce- clear the dye out of the body.
dure as
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recommended by your
provider."
B. "Limit your intake of water
and alcohol following the pro-
cedure."
C. "Do not eat or cook any shell-
fish prior to the procedure."
D. "Stop breastfeeding for
the time frame given by the
provider within the nuclear
medicine department."

14. What neurologic assessment ANS: A

should the nurse perform to Rationale: Cranial nerve I is the olfactory nerve. The client's
gauge the client's function sense of smell could be
of cranial nerve I? assessed by asking him or her to identify common odors.
A. Have the client identify famil- Assessment of papillary reflex
iar odors with the eyes closed. does not address the olfactory function of cranial nerve I. The
B. Assess papillary reflex. Snellen chart would be
C. Utilize the Snellen chart. used to assess cranial nerve II (optic).
D. Test for air and bone conduc-
tion (Rinne test).

15. A client is being given a ANS: A

medication that stimulates the Rationale: Parasympathetic stimulation results in constricted
parasympathetic system. pupils, constricted
Following administration of this bronchioles, increased peristaltic movement, and contracted
medication, the nurse should muscular walls of the
anticipate what effect? urinary bladder.
A. Constricted pupils
B. Dilated bronchioles
C. Decreased peristaltic move-
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ment
D. Relaxed muscular walls of
the urinary bladder

16. A health care provider has pre- ANS: A, C, E

scribed a standard electroen- Rationale: A standard EEG usually takes 45 to 60 minutes.
cephalogram (EEG) test for Typically, a water-soluble
the client. What general instruc- lubricant is used to aid electrode contact. This lubricant is
tions should the nurse provide easily removed with shampoo.
to the client? Select all that Coffee, tea, chocolate, and cola drinks are omitted from the
apply meal before the test because
A. The procedure generally of their stimulating effect. Sedation is not considered because
takes 45 to 60 minutes. it may lower the seizure
B. Please remove all jewelry and threshold in clients and it may alter brain activity. Stimulants,
any metal objects prior to the tranquilizers,
procedure anticonvulsants, and depressants are advised to be held 24
C. This procedure uses a wa- to 48 hours, not 72 hours,
ter-soluble lubricant for elec- prior to the procedure because these medications can alter
trode contact which can be the EEG wave patterns or
easily wiped off and removed mask the abnormal wave patterns of seizure disorders. The
using shampoo client is instructed to eat
D. If you feel nervous about the before the test because keeping the client NPO (nothing by
test I can provide you a light mouth) can alter blood
sedative medication glucose levels and cause changes in brain wave patterns. The
to ease your anxiety client can wear jewelry
E. Please refrain from drinking during the test, although some facilities will request that
coffee and any caffeinated bev- earrings be removed.
erages the morning
prior to the procedure
F. It is required that you with-
hold taking your anticonvulsant

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medication 72 hours
before the procedure.

17. A client is having a "fight or ANS: C

flight response" after receiving Rationale: Sympathetic nervous system stimulation results in
a bad disease prognosis. dilated blood vessels in the
What affect will this have on heart and skeletal muscle, dilated bronchioles, increased se-
the client's sympathetic ner- cretion of sweat, and dilated
vous system? pupils.
A. Constriction of blood vessels
in the heart muscle
B. Constriction of bronchioles
C. Increase in the secretion of
sweat
D. Constriction of pupils

18. In which specific instances ANS: B, C, D

should the nurse assess the Rationale: Cranial nerves are assessed when level of con-
client's cranial nerves? Select sciousness is decreased, with
all that apply. brain stem pathology, or in the presence of peripheral ner-
A. When a neurogenic bladder vous system disease.
develops Abnormalities in muscle tone and involuntary movements are
B. When level of consciousness less likely to prompt the
is decreased assessment of cranial nerves, since these nerves do not di-
C. With brain stem pathology rectly mediate most aspects of
D. In the presence of peripheral muscle tone and movement.
nervous system disease
E. When a spinal reflex is inter-
rupted

19. A client in the OR goes into ma- ANS: C

lignant hyperthermia due to an Rationale: The hypothalamus plays an important role in the

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abnormal reaction to endocrine system because it

the anesthetic. The nurse regulates the pituitary secretion of hormones that influence
knows the brain regulates body metabolism, reproduction,
temperature in which of the stress response, and urine production. It works with the pi-
following areas? tuitary to maintain fluid
A. Cerebellum balance through hormonal release and maintains tempera-
B. Thalamus ture regulation by promoting
C. Hypothalamus vasoconstriction or vasodilatation. The cerebellum, thalamus,
D. Midbrain and midbrain are not
directly involved in temperature regulation.

20. The nurse is planning the care ANS: B

of a client with Parkinson dis- Rationale: Parkinson disease develops from decreased avail-
ease. The nurse should be ability of dopamine, not
aware that treatment will focus acetylcholine, epinephrine, or serotonin.
on what pathophysiologic phe-
nomenon?
A. Premature degradation of
acetylcholine
B. Decreased availability of
dopamine
C. Insufficient synthesis of epi-
nephrine
D. Delayed reuptake of sero-
tonin

21. A client is admitted to the med- ANS: A

ical unit with an exacerbation of Rationale: The hypoglossal nerve is the 12th cranial nerve. It
multiple sclerosis. is responsible for
When assessing this client, the movement of the tongue. None of the other listed nerves
nurse has the client stick out affects motor function in the
the tongue and move it back tongue.
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and forth. What is the nurse as-

sessing?
A. Function of the hypoglossal
nerve
B. Function of the vagus nerve
C. Function of the spinal nerve
D. Function of the trochlear
nerve

22. A trauma client was admitted ANS: C

to the intensive care unit (ICU) Rationale: Sympathetic storm is a syndrome associated with
with a brain injury that changes in level of
resulted in a change in level of consciousness, altered vital signs, diaphoresis, and agitation
consciousness and altered vital that may result from
signs. The client hypothalamic stimulation of the sympathetic nervous system
subsequently became di- following traumatic brain
aphoretic and agitated. The injury. Alterations in cranial nerve or adrenal function would
nurse should recognize which not have this result.
of the
following syndromes as the
most plausible cause of these
symptoms?
A. Adrenal crisis
B. Hypothalamic collapse
C. Sympathetic storm
D. Cranial nerve deficit

23. The nurse is preparing to as- ANS: B, C, D

sess a client with neurologic Rationale: Assessment requires knowledge of the anatomy
dysfunction. What does and physiology of the nervous
accurate and appropriate as- system and an understanding of the array of tests and pro-
sessment require? Select all cedures used to diagnose
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that apply. neurologic disorders. Knowledge about the nursing implica-

A. The ability to select basic tions and interventions related
medications for the neurologic to assessment and diagnostic testing is also essential. Select-
dysfunction ing medications and
B. Understanding of the tests interpreting diagnostic tests are beyond the normal scope of
used to diagnose neurologic the nurse.
disorders
C. Knowledge of nursing inter-
ventions related to assessment
and diagnostic testing
D. Knowledge of the anatomy of
the nervous system
E. The ability to interpret the re-
sults of diagnostic tests

24. When caring for a client with an ANS: C

altered level of consciousness, Rationale: Cranial nerve VII is the facial nerve. An appropriate
the nurse is preparing assessment technique for
to test cranial nerve VII. What this cranial nerve would include observing for symmetry while
assessment technique would the client performs facial
most likely elicit a response movements: smiles, whistles, elevates eyebrows, and frowns.
from cranial nerve VII? Cranial nerve XI (spinal
A. Palpate trapezius muscle accessory) does not affect the muscles of the face. Assessing
while client shrugs shoulders cranial nerve VIII (acoustic)
against resistance. would involve evaluating hearing. Cranial nerve X (vagus)
B. Administer the whisper or does not affect the face.
watch tick test.
C. Observe for facial movement
symmetry, such as a smile.
D. Note any hoarseness in the
client's voice.

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25. A client has been recently diag- ANS: C

nosed with myasthenia gravis. Rationale: In myasthenia gravis, acetylcholine binding to
Which is indicative of a muscle cells is impaired. A
person diagnosed with myas- breakdown essentially occurs in the communication between
thenia gravis? nerves and muscles. This
A. Excessive serotonin activity results in weakness of extremities and difficulties with speech
in the brain and chewing. Many
B. Decreased dopamine activity neurologic disorders are due, at least in part, to an imbalance
in the brain in neurotransmitters.
C. Impairment of acetylcholine Decreased dopamine activity in the brain is suggestive of
binding to muscle cells Parkinson. Excessive or too
D. Defects in the expression of much serotonin activity in the brain can cause a variety of mild
acetylcholine receptors to severe symptoms.
Some of these include high blood pressure, shivering, con-
fusion and/or high fever.
Defects in the expression of acetylcholine receptors is more
indicative of amyotrophic
lateral sclerosis (ALS). ALS affects motor neurons directly.

26. The nurse caring for an ANS: C

80-year-old client knows that Rationale: Tactile sensation is dulled in the older adult client
the client has a preexisting due to a decrease in the
history of dulled tactile sensa- number of sensory receptors. While thorough assessment is
tion. The nurse should first con- necessary, it is possible that
sider what possible cause for this change is unrelated to pathophysiologic processes.
this client's diminished tactile
sensation?
A. Damage to cranial nerve VIII
B. Adverse medication effects
C. Age-related neurologic
changes

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D. An undiagnosed cerebrovas-
cular disease in early adulthood

27. A 72-year-old man has been ANS: D

brought to his primary care Rationale: Although mental processing time decreases with
provider by the client's age, memory, language, and
daughter, who claims that the judgment capacities remain intact. Change in mental status
client has been experiencing should never be assumed to
uncharacteristic lapses in be a normal part of aging.
memory. What principle should
underlie the nurse's assess-
ment and management of this
client?
A. Loss of short-term memory is
normal in older adults, but loss
of long-term
memory is pathologic.
B. Lapses in memory in older
adults are considered benign
unless they have
negative consequences.
C. Gradual increases in con-
fusion accompany the aging
process.
D. Thorough assessment is nec-
essary because changes in cog-
nition are always
considered to be pathologic.

28. A gerontologic nurse educator ANS: A

is providing practice guidelines Rationale: Reaction to painful stimuli may be decreased with
to unlicensed care age. Because pain is an
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providers. Because reaction to important warning signal, caution must be used when hot or
painful stimuli is sometimes cold packs are used. The
blunted in older adults, what older client may be burned or suffer frostbite before being
must be used with caution? aware of any discomfort. Any
A. Hot or cold packs medication is used with caution in older adults, but not be-
B. Analgesics cause of the decreased sense of
C. Anti-inflammatory medica- heat or cold. Whirlpool baths are generally not a routine
tions treatment prescribed for older
D. Whirlpool baths adults.

29. A trauma client in the ICU has ANS: B

been declared brain dead. What Rationale: The EEG can be used to determine that brain
diagnostic test is used activity has ceased.. MRI and CT
in making the best determina- scans have been used to declare brain death by showing an
tion that the brain's electrical absence of blood flow, but
activity has ceased? this is not the best way to determine that brain activity has
A. Magnetic resonance imaging ceased. EMG is not normally
(MRI) used to determine brain death.
B. Electroencephalography
(EEG)
C. Electromyography (EMG)
D. Computed tomography (CT)

30. A client is scheduled for CT ANS: C

scanning of the head because Rationale: Preparation for CT scanning includes teaching the
of a recent onset of client about the need to lie
neurologic deficits. What quietly throughout the procedure. If the client were having an
should the nurse tell the client MRI, metal and noise
in preparation for this test? would be appropriate teaching topics. There is no need to
A. "No metal objects can enter fast prior to a CT scan of the
the procedure room." brain.
B. "You need to fast for 8 hours
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prior to the test."

C. "You will need to lie still
throughout the procedure."
D. "There will be a lot of noise
during the test."

31. A client for whom the nurse ANS: D

is caring has positron emission Rationale: Key nursing interventions for PET scan include ex-
tomography (PET) plaining the test and
scheduled. In preparation, teaching the client about inhalation techniques and the sen-
what should the nurse explain sations (e.g., dizziness,
to the client? lightheadedness, and headache) that may occur. A PET scan
A. "The test will temporarily does not impede blood flow
limit blood flow through the through the brain. An allergy to iodine precludes the dye for
brain." an MRI, and loud noise is
B. "An allergy to iodine heard in an MRI.
precludes getting the ra-
dio-opaque dye."
C. "The client will need to en-
dure loud noises during the
test."
D. "The test may result in dizzi-
ness or lightheadedness."

32. A client is scheduled for a myel- ANS: A

ogram, and the nurse explains Rationale: A myelogram is an x-ray of the spinal subarachnoid
to the client that this is space taken after the
an invasive procedure, which injection of a contrast agent into the spinal subarachnoid
assesses for any lesions in the space through a lumbar
spinal cord. The nurse should puncture. Client preparation for a myelogram would be sim-
explain that the preparation is ilar to that for lumbar
similar to which of the following
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neurologic tests? puncture. The other listed diagnostic tests do not involve
A. Lumbar puncture lumbar puncture.
B. MRI
C. Cerebral angiography
D. EEG

33. The health care provider has ANS: B

prescribed a somatosensory Rationale: SERs are used to detect deficits in the spinal cord
evoked responses (SERs) or peripheral nerve
test for a client for whom the conduction and to monitor spinal cord function during sur-
nurse is caring. The nurse is jus- gical procedures. The test is
tified in suspecting that this also useful in the diagnosis of demyelinating diseases, such
client may have a history of as multiple sclerosis and
what type of neurologic disor- polyneuropathies, where nerve conduction is slowed. The test
der? is not done to diagnose
A. Hypothalamic disorder hypothalamic disorders, brainstem deficits, or diabetic neu-
B. Demyelinating disease ropathies.
C. Brainstem deficit
D. Diabetic neuropathy

34. A client had a lumbar punc- ANS: C, E

ture performed at the outpa- Rationale: Contacting the client and family after diagnostic
tient clinic and the nurse testing enables the nurse to
phoned the client and family determine whether they have any questions about the proce-
that evening. What does this dure, whether the client
phone call enable the nurse to had any untoward results, and what to do should complica-
determine? Select all that ap- tions arise. Since the test was
ply. done as an outpatient; monitoring and care are being pro-
A. What the client's and family's vided by the family. The health
expectations of the test are. of the client becomes a team effort so any communication by
B. Whether the client's family the nurse should include
had any questions about why both parties. The other listed information should have been
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the test was necessary. elicited from the client and

C. Whether the client has had family prior to the test.
any complications from the
test.
D. Whether the client under-
stood accurately why the test
was done.
E. The necessary steps for the
client and family to take should
complications arise.

35. A client is currently being stim- ANS: D

ulated by the parasympathetic Rationale: The parasympathetic division of the nervous sys-
nervous system. What tem causes contraction
effect will this nervous stimula- (stimulation) of the urinary bladder muscles whereas the
tion have on the client's blad- sympathetic division produces
der? relaxation (inhibition) of the urinary bladder.
A. Urinary retention
B. Bladder spasms
C. Urge incontinence
D. Bladder contract

36. The nurse is performing a neu- ANS: B

rologic assessment of a client Rationale: If the client is not alert or able to follow commands,
whose injuries have the examiner observes for
rendered the client unable to eye opening; verbal response and motor response to stimuli,
follow verbal commands. How if any; and the type of
should the nurse proceed stimuli needed to obtain a response. Vital signs and diagnos-
with assessing the client's level tic testing are appropriate,
of consciousness (LOC)? but neither will allow the nurse to gauge the client's LOC.
A. Assess the client's vital signs Inability to follow commands
and correlate these with the
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client's baselines. does not necessarily denote an absolute lack of conscious-

B. Assess the client's eye open- ness.
ing and response to stimuli.
C. Document that the client cur-
rently lacks a level of conscious-
ness.
D. Facilitate diagnostic testing
in an effort to obtain objective
data.

37. In the course of a focused neu- ANS: B

rologic assessment, the nurse Rationale: Muscle tone (the tension present in a muscle at
is palpating the client's rest) is evaluated by palpating
major muscle groups at rest various muscle groups at rest and during passive movement.
and during passive movement. Data from this assessment
Data gleaned from this do not allow the nurse to ascertain the client's dexterity,
assessment will allow the nurse reflexes, or motor symmetry.
to describe which of the follow-
ing aspects of neurologic
function?
A. Muscle dexterity
B. Muscle tone
C. Motor symmetry
D. Deep tendon reflexes

38. The neurologic nurse is testing ANS: D

the function of a client's cere- Rationale: Cerebellar and basal ganglia influence on the mo-
bellum and basal ganglia. tor system is reflected in
What action will most accurate- balance control and coordination. Coordination in the hands
ly test these structures? and upper extremities is
A. Have the client identify the tested by having the client perform rapid, alternating move-
location of a cotton swab on his ments and point-to-point
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or her skin with the testing. The cerebellum and basal ganglia do not mediate
eyes closed. cutaneous sensation or
B. Elicit the client's response to judgment.
a hypothetical problem.
C. Ask the client to close his or
her eyes and discern between
hot and cold stimuli.
D. Guide the client through the
performance of rapid, alternat-
ing movements.

39. During the performance of the ANS: C

Romberg test, the nurse ob- Rationale: Slight swaying during the Romberg test is normal,
serves that the client but a loss of balance is
sways slightly. What is the abnormal and is considered a positive Romberg test. Slight
nurse's most appropriate ac- swaying is not a significant
tion? threat to the client's safety. The Rinne test assesses hearing,
A. Facilitate a referral to a neu- not balance.
rologist.
B. Reposition the client supine
to ensure safety.
C. Document successful com-
pletion of the assessment.
D. Follow up by having the client
perform the Rinne test.

40. The nurse is providing informa- ANS: C

tion to a client about neurolog- Rationale: Several neurologic disorders are associated with
ical disorders associated genetic abnormalities. These
with genetic defects. The nurse diseases can have distinct inheritance patterns including: au-
knows which disease is consid- tosomal dominant,
ered an autosomal Autosomal recessive, or X-linked. Autosomal dominant dis-
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 CHAPTER 60: ASSESSMENT OF NEUROLOGIC FUNCTION
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dominant disorder? eases include: familial

A. Duchenne muscular dystro- Alzheimer disease, myotonic dystrophies, Von Hippel-Lindau
phy syndrome, Huntington
B. Parkinson disease disease, neurofibromatosis, and cerebral arteriopathy.
C. Huntington disease Duchenne muscular dystrophy
D. Fragile X syndrome and fragile X syndrome are X-linked disorders. Parkinson
disease does not have a distinct
inheritance pattern.

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