HESI Case Study: Neurological assessment – Flashcards

The RN beings the admission assessment with the collection of assessment data that is immediately entered into her tablet. 1. When eliciting data bout possible neurological problems, which questions would the RN ask the client? (select all that apply -"Do you have any difficulty speaking or swallowing?" -"Do you have any numbness, tingling or weakness in your extremities?" -"When you passed out, did you hit your head? If so, what part of your head did you hit?" -"Have you had any headaches? If so, describe frequency and location." headaches can indicate hypertension or intracranial bleeding -"Have you ever heard voices inside your head that no one else hears?"

2. Based on Mrs. Richardson's recent history of loss of consciousness and falling, what additional assessment takes priority? - Two point discrimination -Pedal Pulse Volume -Blood pressure and Heart rate/rhythm -DTRs The RN measures Mrs. Richardson's vital signs and assess her level of consciousness and then proceeds to interview the client

To determine what happened to the client when she experienced loss of consciousness, the RN should ask Mrs. Richardson which question(s)? Select all that apply -"Can you stick out your tongue?" -"Did it feel like the room was suddenly spinning before you fell?" -"Does the dizziness occur when you change positions?" -"Do you have any problems with smell?" -"Do you ever feel lightheaded or dizzy?"

4. During the client interview, the RN observes Mrs. Richardson's speech pattens. Mrs. Richardson seems to have difficulty choosing/forming some words. What action should the RN take? -Allow the client to respond and ignore her difficulty to avoid embarrassment -Offer to complete the interview at a later time after the client has rested -Fill in the conversation with the words the client is attempting to say -Affirm the client's difficulty and question her about when this first started.

Before continuing the interview and assessment, the RN enters the following initial data collected into her tablet: Mrs. R demonstrates difficulty speaking and she previously reported feeling weak, passing out, and falling at home. Her vital signs are currently T97F, BP 140/88, HR 92, RR 18 5. What terminology should accurately be included in the RN's documentation? -Tachycardia -Dysphagia -Paresis -Syncope

6. In documenting that pt had difficulty speaking. Before describing this finding on the assessment form, what additional data should the RN consider? -How many words per minute the client is able to speak -The client's ability to comprehend what she is being asked -If any mouth drooping is observed when the client spoke -Whether the client is able to read the RN's lips accurately

While continuing the client interview, the RN assesses the client's mental status. As the interview continues, Mrs. Richardson occasionally struggles to choose and form words, but seems comfortable and relaxed. The RN provides a quiet, calm environment, allowing the client ample time to respond to the interview questions. Mrs. R asks the RN what her room # is, stating she needs to let her daughter know where she is. 7. Which assessment by the RN accurately reflects the client's statement? -Oriented to situation -Loss of immediate memory -Disoriented to place -Loss of recent memory

8. To assess Mrs. R's recent memory more completely, what action should the RN take? -Observe her cooperation in answering interview questions. -List four words and ask her to repeat them back to the RN -Encourage her to reminisce about the birth of her daughter -Question her about how she arrived at the hospital

9. Which interview data provides the RN with information related to the client's judgement? -Reminiscing about the birth of her daughter caused the client to cry gently. -Repeating back a list of four words made the client anxious and uncomfortable -The client indicated the need to notify her daughter that she is in the hospital -The client was cooperative but vague in describing how her neighbor found her.

10. The RN observes the client moving her eyes through the six cardinal fields of gaze by following an object or fingers without moving her head. Which cranial nerves are tested when the RN is evaluating the extra ocular movements? (select all that apply) -Oculomotor (CN III) -Trochlear (CNIV) -Abducens (CN VI) -Facial (CNVII) -Trigeminal (CNV)

11. After the RN asks the Client to close both eyes what is the next action the RN should take? -Move the penlight away from the pupil -Observe the constriction of the pupil -Hold a penlight to the side of one eye -Shine a penlight into one pupil

12. To continue the CN assessment, the RN asks patient to first smile, then frown, then show her teeth. While the client performs these task, what should RN do? -Gently palpate for swelling over the cheeks -Apply light pressure over the facial nerve -Note how quickly Mrs. R completes each task -Observe for symmetric facial movement

13. The RN tests cranial nerve XI by asking the client to shrug her shoulders. What action should the RN perform? -Apply resistance to the client's shoulders -Slowly elevate both of the client's arms -Internally rotate each of the client's shoulders -Observe the movement of the client's clavicles

14. Since Mrs. R is lying in bed, which action should the RN take to observe small muscle movement and coordination? -Stroke the lateral sides of the sole of each foot -Use a reflex hammer to elicit arm movement -Ask the client to touch her thumb to each finger -Assist the client to sit on the side of the bed

The RN observes that Mrs R lacks coordination when touching her thumb to the fingers on the left side and decides to further assess her upper extremity muscle strength. To assess upper extremity muscle strength, the RN stands facing the client and holds out both hands toward client. The RN asks the client to grip two of the RNs fingers and one hand and two fingers with the other hand. 15. What instruction should the RN provide next? -Pull my fingers forward toward you, one hand at a time. -Push my fingers back, using both hands at the same time. - squeeze my fingers with one hand, then with the other - squeeze my fingers with one hand, then with the other

Mrs. R's LUE seems to be weaker than her RUE 16. What additional assessment should the RN perform to validate the finding of unilateral upper extremity weakness? -Complete a Romberg test -Check for a placing reflex -Observe for decorticate posturing -Perform a palmer drift test

After validating the finding of left-sided upper extremity weakness, the RN next assesses Mrs. R's sensory function. 17. The RN uses a tuning fork to evaluate what sensory function? -Vibration -Passive Motion -Pain -Two point discrimination

18. Next, the RN asks Mrs. R to close her eyes. The RN places the tuning fork in the palm of Mrs. R's left hand and asks her to identify what she is holding. Mrs. R is unable to identify the tuning fork. What action should the RN take in response to this finding? -Hold the tuning fork on the back of her hand while she tries to identify it. -Ask the client to open her eyes and identify the object she is holding -Place a comb in the client's life hand and ask her to identify the object -Document that the client is exhibiting left-sided astereognosis Mrs. R is able to identify a comb when it is placed in her right hand, but is unable to identify the comb when it is placed in her left hand

The RN continues the neurological assessment by evaluating Mrs R's DTRs. 19. The RN begins by testing the client's biceps reflex. With the client's forearm resting on the RN's forearm and the RN's thumb over the biceps tendon, what action should the RN take next to test the client's biceps reflex? -Strike the thumb with the reflex hammer -Instruct the client to repeatedly clench her fist -Extend and externally rotate the client's forearm -Ask the client to contract the biceps muscle

20. The RN observes contraction of the biceps muscle and flexion of the forearm in response to the attempt to elicit the biceps reflex. What action should the RN take in response to this finding? -Explain to the client that the reflex response was normal -Repeat the test at the same location to confirm the finding -Document that clonus was elicited by the reflex testing -Record the finding as a 4+ deep tendon biceps reflex

Shortly after completing the admission assessment, the RN returns to the client's room and notes a change in the client's condition. Mrs. R is slurring all of her words. Further assessment reveals that Mrs. R is no longer able to move her left arm and leg, and within a few minutes she no longer responds to the RN's questions. The RN quickly assesses the client's LOC by checking for a response to varying stimuli 21. What stimuli should the RN use first to attempt to elicit a response from the client? -Call the client's name -vigorously shake the client's shoulder -Punch the client's trapezius muscle -lightly tough the client's arm

To objectively assess the client's LOC, the RN uses GCS. 22. What data should the RN obtain to complete the client's GCS rating (select all that apply) -Verbal response -Babinski reflex -Eye opening response -Motor response -Pupillary reponse

Mrs. R's daughter, Nakida, has arrived and the RN explains that her mother's condition has worsened. Nakida cries and tells the RN that her mother had often told her that she had lived a full, long life and did not want any extraordinary measures in the event of a serious illness. The RN assesses Mrs R's end of life wishes. 23. In assessing the client's end of life wishes, the RN remember's Mrs. R's husband is deceased. It is most important for the RN to communicate with which person? -The client's designated power of attorney for health care. -The client's physician, with whom she has discussed her wishes. -The client's minister from Baptist congregation where she is a member -The client's daughter Nakida, her oldest child