Exam (elaborations)

Neurological Assessment Case Study UPDATED Exam Questions and CORRECT Answers

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Course
Neurological Assessment

Institution
Neurological Assessment

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Uploaded on September 12, 2024
Number of pages 11
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Type Exam (elaborations)
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neurological assessment
neurological
neurological assessment case study

Institution Neurological Assessment
Course Neurological Assessment

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Neurological Assessment Case Study
UPDATED Exam Questions and
CORRECT 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 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.

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.

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 - CORRECT
ANSWER- ✔✔A. Affirm the client's difficulty and ask about when this first started.

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