Exam 4 Neuro/Burns (with correct answers)

The nurse is preparing to assess a patient's cognitive function. What should the nurse include in this assessment? correct answers orientation to time, place, and person, and ability to recall recent and past events The nurse is preparing to assess a patient's cranial nerve XI (spinal accessory). What should the nurse ask the patient to complete this assessment? correct answers Shrug the shoulders and turn the head against resistance Normally a patient can differentiate between soft and sharp and can feel vibrations accurately. What should the nurse do to assess a patient's sensory function? correct answers touch both sides of various parts of the body with a sharp and a dull object A patient is exhibiting a lack of coordination, clumsy movements, and an unbalanced gait. What term should the nurse use when documenting these observations? correct answers ataxia To conduct the Romberg test, the nurse asks the patient to stand with the feet together and eyes closed. What must the nurse observe for the test to be considered normal? correct answers minimal swaying for up to 20 seconds The nurse asks the patient to walk heel-to-toe, on the toes, and then on the heels. What function is the nurse assessing? correct answers cerebellar - coordination/balance (CSF) fluid is normal characteristics correct answers CSF is clear and colorless. The nurse is assessing a patient's muscle strength and movement. What should the nurse do when completing this assessment? correct answers observe whether strength and movement are bilaterally equal and strong lower motor neuron injuries. What type of reflexes should the nurse expect to assess in this patient? correct answers decreased The nurse is planning to assess an adult patient with a neurological problem for abnormal posturing. For what postures should the nurse specifically assess? SATA correct answers 1. decorticate - abnormal flexion 2. decerebrate - abnormal extension (worse) A patient is being treated for a common neurological disease that is characterized by abnormal cell firing in the brain. For what should the nurse assess in this patient? correct answers siezures A patient experiencing extreme emotional stress is observed to be exhibiting both tachycardia and tachypnea. Which component of the patient's nervous system is responsible for normalizing the patient's response? correct answers parasympathetic