What should the nurse assess to test the neurological system?
Which of the following assessment techniques should the nurse use to determine a client’s stereognosis ? With the client’s eyes closed, place a coin or key in hand and ask him or her to identify the object.
A nurse holds the patient’s relaxed arm with the elbow flexed at a 90-degree angle, places a thumb over the appropriate tendon in the antecubital fossa, and strikes the thumb with the pointed end of the reflex hammer. A Pronation of the left forearm is a normal response for the brachioradialis deep tendon reflex .
How would a nurse test a patient’s superficial reflex ? Test the reactions elicited by stroking the skin. Superficial reflexes are also called cutaneous reflexes . Here, the sensory receptors are in the skin rather than in the muscles.
Reflex tests are performed as part of a neurological exam, either a mini-exam done to quickly confirm integrity of the spinal cord or a more complete exam performed to diagnose the presence and location of spinal cord injury or neuromuscular disease. Deep tendon reflexes are responses to muscle stretch.
Altered mentation and decreasing level of consciousness are usually the first signs of neurological deterioration . Nurses should be alert to even subtle changes in the client’s behavior and level of responsiveness.
Which of the following tests would be most appropriate for the nurse to use when assessing motor function of a client’s trigeminal nerve ? Palpate temporal and masseter muscles while client clenches the teeth. A client has presented with signs and symptoms that are suggestive of Bell’s palsy.
17. When a nurse asks a patient to place the right arm behind the head, the nurse is testing for which range of motion ? A Flexion of the elbow requires the patient to flex the elbow, but the elbow flexion is usually tested by asking the patient to bend the elbow so that the fingers are touching the shoulder.
Cranial nerve XII
Which patient behavior indicates to the nurse that the patient’s facial cranial nerve (CN VII) is intact ? The sides of the mouth are symmetric when the patient smiles. The patient’s eyes move to the left, right, up, down, and obliquely.
Which tests should the nurse perform to assess cerebellar function in a patient ? The Romberg test is done to assess balance. The finger-to-nose test is done to assess upper limb coordination. This ability of an individual to perform these tests determines the cerebellar function of the patient .
How would a nurse test a patient’s superficial reflex ? Test the reactions elicited by stroking the skin.
Terms in this set (20) What should the patient’s response be when the nurse tests the cremasteric reflex ? While assessing the deep tendon reflexes in a patient , the nurse finds that the responses are very brisk and hyperactive, with clonus.
When reflex responses are absent this could be a clue that the spinal cord, nerve root, peripheral nerve, or muscle has been damaged. When reflex response is abnormal , it may be due to the disruption of the sensory (feeling) or motor (movement) nerves or both.
Spinal Reflexes. Spinal reflexes include the stretch reflex , the Golgi tendon reflex , the crossed extensor reflex , and the withdrawal reflex .
After obtaining the reflex on one side, always go immediately to the opposite side for the same reflex so that you can compare them. Jaw Jerk. Place the tip of your index finger on a relaxed jaw, one that is about one-third open. Biceps Reflex. Triceps Reflex . Brachioradialis Reflex . Finger Jerk . Knee Jerk. Ankle Jerk.