A nurse is beginning their clinical shift in a Neurological…
A nurse is beginning their clinical shift in a Neurological ICU unit. The Glasgow Coma Scale (GCS) is used daily as part of the neurological physical exam. The nurse understands the following assessments are included in the GCS scale: Choose all that apply?
Read DetailsIn completing a neurologic assessment of a one-month-old inf…
In completing a neurologic assessment of a one-month-old infant, the nurse notes a lack of response to noise or stimulation. The mother reports that in the last few days, “the baby has been sleeping all day and when he does awake-all he does is cry!” The nurse hears that the infant’s cry is high pitched and shrill. When asked, the mother says this “cry is different from the baby’s general cries and she has a hard time getting him to stop crying.” What is the most appropriate action by the nurse?
Read DetailsA 72-year-old woman is in the eye clinic for a checkup. She…
A 72-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the newspaper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has loss of central vision but her peripheral vision is normal. These findings suggest?
Read DetailsThe nurse is assessing the neurologic status of a patient wh…
The nurse is assessing the neurologic status of a patient who has a documented upper motor neuron lesion (UMN). With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient’s toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as:
Read DetailsAfter a roll-over motor vehicle accident, the Emergency depa…
After a roll-over motor vehicle accident, the Emergency department nurse checks for the “corneal blink reflex” in a newly admitted patient. The patient’s eyes blink when touched with a cotton ball to the outer canthus bilaterally. The nurse can chart that ________________ are intact. Fill in the blank.
Read DetailsDuring an assessment of a 62-year-old female patient, the nu…
During an assessment of a 62-year-old female patient, the nurse notices the patient has a stooped posture, a shuffling walk with short steps, a flat facial expression, and “pill-rolling” finger movements. These findings would be consistent with:
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