Chapter 24, Neurologic System: Assessing the Neurologic System-Sherpath

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Question 1 of 18

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Which elements of the pupils should be evaluated as part of the assessment of the cranial nerves of the eyes?

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    • SizeThe nurse should evaluate the size of the pupils as part of the assessment of the cranial nerves of the eyes.
    • ColorThe nurse would not evaluate eye color as part of the assessment of the cranial nerves of the eyes.
  • Correct
    • EqualityThe nurse should evaluate the equality of the pupils as part of the assessment of the cranial nerves of the eyes.
    • DroopingThe nurse would assess the eyelids for drooping, not the pupils.
  • Correct
    • Response to lightThe nurse should evaluate the response of the pupils to light as part of the assessment of the cranial nerves of the eyes.

Question 2 of 18

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Which type of assessment of the cranial nerves of the eyes should the nurse perform in order to evaluate cranial nerve II?

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    • Visual acuity testThe nurse should perform a visual acuity test to evaluate cranial nerve II, as it is a cranial nerve of the eyes that transmits information to the brain.
  • Correct
    • Visual fields testThe nurse should perform a visual fields test to evaluate cranial nerve II, as it is a cranial nerve of the eyes that transmits information to the brain.
    • Taste identificationThe nurse would test the patient’s ability to identify taste as an evaluation of cranial nerves VII and IX, not cranial nerve II.
    • Odor identificationThe nurse would test the patient’s ability to identify odor as an evaluation of cranial nerve I, not cranial nerve II.
  • Correct
    • Ophthalmologic examinationThe nurse should perform an ophthalmologic examination to evaluate cranial nerve II, as it is a cranial nerve of the eyes that transmits information to the brain.

Question 3 of 18

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In which ways should the nurse test the pupils for response to light as part of the assessment of the cranial nerves of the eyes?

  • Correct
    • Swinging flashlight testThe swinging flashlight test is used to test the patient’s response to light as part of the assessment of the cranial nerves of the eyes.
  • Correct
    • Direct response to lightThe nurse should test the pupils for response to direct light by shining a penlight into one pupil and evaluating for constriction.
    • Indirect response to lightThe nurse would not evaluate the pupils for indirect response to light as part of the assessment of the cranial nerves of the eyes.
  • Correct
    • Consensual response to lightThe nurse should test the pupils for consensual response to light by shining a penlight into one eye and evaluating the opposite eye for consensual constriction.
    • Constriction to accommodationThe nurse would test the patient’s pupils for constriction to accommodation as part of the assessment of the cranial nerves of the eye; however, this does not test the pupil’s response to light.

Question 4 of 18

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Which elements should be assessed to evaluate the vagus nerve (CN X)?

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    • TasteThe nurse should test the patient’s ability to identify sour and bitter tastes on either side of the tongue to evaluate the vagus nerve (CN X).
    • SmellThe nurse would test the patient’s ability to smell to evaluate the olfactory nerve, not the vagus nerve (CN X).
    • SightThe nurse would test the patient’s ability to see to evaluate the optic nerve, not the vagus nerve (CN X).
  • Correct
    • Gag reflexThe nurse should assess the patient’s gag reflex to evaluate the vagus nerve (CN X).
  • Correct
    • SwallowingThe nurse should assess the patient’s ability to swallow to evaluate the vagus nerve (CN X).

Question 5 of 18

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When evaluating the vagus nerve (CN X), the nurse should inspect which aspect of the palate and uvula?

    • SizeThe size of the palate and uvula do not help the nurse evaluate the vagus nerve (CN X).
    • ColorThe color of the palate and uvula do not help the nurse evaluate the vagus nerve (CN X).
    • ShapeThe shape of the palate and uvula do not help the nurse evaluate the vagus nerve (CN X).
  • Correct
    • SymmetryWhen evaluating the vagus nerve (CN X), the nurse should inspect the symmetry of the palate and uvula because the vagus nerve provides motor supply to the pharynx.

Question 6 of 18

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Which aspect of the tongue should the nurse evaluate as part of the hypoglossal (CN XII) nerve assessment?

    • LengthThe length of the tongue would not help the nurse evaluate the hypoglossal nerve (CN XII).
  • Correct
    • StrengthThe nurse would assess the strength of the tongue as part of the evaluation of the hypoglossal nerve (CN XII) because the hypoglossal nerve innervates the tongue.
    • ColorThe color of the tongue would not help the nurse evaluate the hypoglossal nerve (CN XII).
    • TasteThe ability of the tongue to taste would not help the nurse evaluate the hypoglossal nerve (CN XII).

Question 7 of 18

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When assessing the trigeminal nerve (CN V), which aspects should the nurse evaluate?

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    • Corneal reflexThe nurse should evaluate the corneal reflex when assessing the trigeminal nerve (CN V) because the trigeminal nerve innervates the muscles of the face.
  • Correct
    • Facial atrophyThe nurse should evaluate the presence of facial atrophy to assess the trigeminal nerve (CN V) because the trigeminal nerve innervates the muscles of the face.
  • Correct
    • Facial sensationThe nurse should evaluate facial sensation to assess the trigeminal nerve (CN V) because the trigeminal nerve innervates the muscles of the face.
  • Correct
    • Strength of the jawThe nurse should evaluate the strength of the jaw to assess the trigeminal nerve (CN V) because the trigeminal nerve innervates the muscles of the face.
    • Location of the noseThe nurse would not evaluate the location of the nose when assessing the trigeminal nerve.

Question 8 of 18

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Which elements of the face should the nurse assess when evaluating the facial cranial nerve (CN VII) for motor function?

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    • LipsThe nurse would assess the lips by asking the patient to purse the lips and blow when evaluating the facial cranial nerve (CN VII) for motor function.
  • Correct
    • EyesThe nurse would assess the ability of the patient to squeeze the eyes shut when evaluating the facial cranial nerve (CN VII) for motor function.
    • NoseThe nurse would not assess the nose as part of the evaluation of motor function of the facial cranial nerves. The nose can be assessed on inspection.
  • Correct
    • CheeksThe nurse would assess the ability of the patient to puff out the cheeks when evaluating the facial cranial nerve (CN VII) for motor function.
  • Correct
    • ForeheadThe nurse would assess the forehead by asking the patient to raise the eyebrows when evaluating the facial cranial nerve (CN VII) for motor function.

Question 9 of 18

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Which sensory elements should the nurse assess when evaluating the acoustic nerve (CN VIII)?

    • TasteThe nurse would assess the patient’s taste when evaluating CN VII, IX, X, or XII, but not when evaluating the acoustic nerve (CN VIII).
    • SmellThe nurse would assess the patient’s sense of smell when evaluating the olfactory nerve (CN I), not the acoustic nerve (CN VIII).
  • Correct
    • HearingThe nurse would assess the patient’s hearing when evaluating the acoustic nerve (CN VIII).
  • Correct
    • BalanceThe nurse would assess the patient’s balance when evaluating the acoustic nerve (CN VIII).
    • Sensitivity to touchThe nurse would assess the patient’s sensitivity to touch when evaluating the trigeminal nerve (CN V), not the acoustic nerve (CN VIII).

Question 10 of 18

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Which superficial reflexes should the nurse evaluate?

    • BicepsThe biceps reflex is a deep tendon reflex, not a superficial reflex assessed by the nurse.
  • Correct
    • PlantarThe plantar reflex is a superficial reflex that is typically evaluated.
    • AchillesThe Achilles tendon reflex is a deep tendon reflex, not a superficial reflex, assessed by the nurse.
  • Correct
    • AbdominalThe abdominal reflex is a superficial reflex that may be evaluated.
  • Correct
    • CremastericThe cremasteric reflex is a superficial reflex that may be evaluated.

Question 11 of 18

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Identify the reflex being assessed.

1

2

3

4

Correct Answers:

1

2

3

4

Submitted Answers:

Correct

1 Biceps

Correct

2 Brachioradial

Correct

3 Triceps

Correct

4 Achilles

Question 12 of 18

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When assessing the cremasteric reflex, which area of the patient’s body would the nurse assess?

    • FootThe nurse would assess the foot to evaluate the plantar reflex, not the cremasteric reflex.
    • ArmThe nurse would assess the arm to evaluate the triceps reflex and the biceps reflex, not the cremasteric reflex.
  • Correct
    • ThighThe nurse should assess the inner portion of a male patient’s thigh to evaluate the cremasteric reflex.
    • AbdomenThe nurse would assess the abdomen to evaluate the abdominal reflex, not the cremasteric reflex.

Question 13 of 18

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The nurse should assess rapid rhythmic alternating movements by asking the patient to make which movements?

    • Snap the fingersThe nurse cannot assess the patient’s rapid rhythmic alternating movements by asking the patient to snap the fingers.
    • Clap the hands togetherThe nurse cannot assess the patient’s rapid rhythmic alternating movements by asking the patient to clap the hands together.
  • Correct
    • Touch a thumb to a fingerThe nurse can assess the patient’s rapid rhythmic alternating movements by asking the patient to touch a thumb to a finger.
    • Bend one finger backwardThe nurse cannot assess the patient’s rapid rhythmic alternating movements by asking the patient to bend a finger backward.
  • Correct
    • Alternately turn the palms of the hands up and downThe nurse can assess the patient’s rapid rhythmic alternating movements by asking the patient to alternate turning the palms of the hands up and down.

Question 14 of 18

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Which aspects of involuntary movements should the nurse assess as part of a coordination and fine motor skills evaluation?

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    • RateThe nurse should assess the rate of the patient’s involuntary movements as part of the evaluation of coordination and fine motor skills.
  • Correct
    • QualityThe nurse should assess the quality of the patient’s involuntary movements as part of the evaluation of coordination and fine motor skills.
  • Correct
    • RhythmThe nurse should assess the rhythm of the patient’s involuntary movements as part of the evaluation of coordination and fine motor skills.
    • SymmetryThe nurse would not assess the symmetry of the patient’s involuntary movements as part of the evaluation of coordination and fine motor skills. The symmetry of the patient’s movements is unrelated to coordination.
  • Correct
    • Affected body partsThe nurse should assess the body parts affected by the patient’s involuntary movements as part of the evaluation of coordination and fine motor skills.

Question 15 of 18

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The nurse should use which tests to assess the accuracy of the patient’s movements?

    • Hand-to-toes testTouching a hand to the toes will not allow the nurse to evaluate the accuracy of the patient’s movements.
  • Correct
    • Finger-to-nose testThe nurse should evaluate the ability of the patient to touch a finger to the nose to assess the accuracy of the patient’s movements.
  • Correct
    • Finger-to-finger testThe nurse should evaluate the ability of the patient to touch a finger to another finger to assess the accuracy of the patient’s movements.
    • Ear-to-shoulder testTouching an ear to a shoulder will not allow the nurse to evaluate the accuracy of the patient’s movements.
  • Correct
    • Heel-to-shin testThe nurse should evaluate the ability of the patient to touch the heel to the shin to assess the accuracy of the patient’s movements.

Question 16 of 18

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The nurse would evaluate primary and cortical sensory functions by having the patient identify sensory stimuli in which parts of the body?

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    • FeetThe nurse would ask the patient to identify sensory stimuli in the feet to evaluate primary and cortical sensory functions.
  • Correct
    • HandsThe nurse would ask the patient to identify sensory stimuli in the hands to evaluate primary and cortical sensory functions.
  • Correct
    • Lower legsThe nurse would ask the patient to identify sensory stimuli in the lower legs to evaluate primary and cortical sensory functions.
  • Correct
    • Lower armsThe nurse would ask the patient to identify sensory stimuli in the lower arms to evaluate primary and cortical sensory functions.
    • ShouldersThe nurse would not ask the patient to identify sensory stimuli in the shoulders to evaluate primary and cortical sensory functions.

Question 17 of 18

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Which elements of the patient’s primary sensory function would the nurse assess?

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    • TemperatureThe nurse would assess the ability to sense temperature changes when evaluating the patient’s primary sensory function.
  • Correct
    • Joint positionThe nurse would assess the ability to sense changes in the position of joints when evaluating the patient’s primary sensory function.
    • GraphesthesiaThe nurse would assess graphesthesia, or the ability to identify writing on the skin, when evaluating cortical sensory function, not primary sensory function.
  • Correct
    • Superficial painThe nurse would assess the ability to sense superficial pain when evaluating the patient’s primary sensory function.
  • Correct
    • Superficial touchThe nurse would assess the ability to sense superficial touch when evaluating the patient’s primary sensory function.

Question 18 of 18

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Which cortical sensory function would the nurse assess by drawing a number 8 on the patient’s hand?

    • StereognosisStereognosis, or the ability to recognize objects by touch, is not assessed by drawing a number 8 on a patient’s hand.
  • Correct
    • GraphesthesiaGraphesthesia, or the ability to identify writing on the skin, is the cortical sensory function assessed by drawing a number 8 on the patient’s hand.
    • Superficial painThe ability to feel superficial pain tests the primary sensory functions, not the cortical sensory functions and would not be assessed by drawing a number 8 on the patient’s hand.
    • Extinction phenomenonExtinction phenomenon, or the ability to feel touch sensations, is not assessed by drawing a number 8 on the patient’s hand.