Page 387 - Saunders Comprehensive Review For NCLEX-RN

a. Assess muscle tone, including strength
and equality.
b. Assess for voluntary and involuntary
movements and purposeful and
nonpurposeful movements.
c. This component of the neurological
examination may be performed during
assessment of the musculoskeletal
system.
9. Cerebellar function
a. Monitor gait as the client walks in a
straight line, heel to toe (tandem
walking).
b. Romberg’s test: Client is asked to stand
with the feet together and the arms at
the sides and to close the eyes and hold
the position; normally the client can
maintain posture and balance.
c. If appropriate, ask the client to perform
a shallow knee bend or to hop in place
on 1 leg and then the other.
10. Coordination
a. Assess by asking the client to perform
rapid alternating movements of the
hands (e.g., turning the hands over
and patting the knees continuously).
b. The nurse asks the client to touch the
nurse’s finger, then his or her own
nose; the client keeps the eyes open
and the nurse moves the finger to
different spots to ensure that the
client’s movements are smooth and
accurate.
c. Heel-to-shin test: Assist the client into a
supine position, then ask the client to
place the heel on the opposite knee and
run it down the shin; normally the
client moves the heel down the shin in
a straight line.
11. Sensory function
a. Pain: Assess by applying an object with
a sharp point and one with a dull point
to the client’s body in random order;
ask the client to identify the sharp and
dull feelings.
b. Light touch: Brush a piece of cotton
over the client’s skin at various
locations in a random order and ask

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