Nursing Interview Guide to Collect Subjective Data From the Client

Questions Rationale
Current Symptoms
1. Do you experience headaches? Morning headaches that subside after arising may be an early sign of increased
Use COLDSPA to further explore. intracranial pressure such as with a brain tumor
2. Do you experience seizures Seizures occur with epilepsy, metabolic disorders, head injuries, and high fevers.
(altered or loss of consciousness
that occurs with involuntary
muscle movements and sensory
disturbances)?
3. Do you experience dizziness or Dizziness or lightheadedness may be related to carotid artery disease, cerebellar
lightheadedness or problems with abscess, Ménière’s disease, or inner ear infection. Imbalance and difficulty
balance or coordination? coordinating or controlling movements are seen in neurologic diseases involving the
cerebellum, basal ganglia, extrapyramidal tracts, or the vestibular part of cranial nerve
VIII (acoustic). Diminished cerebral blood flow and vestibular response may increase
the risk of falls.
4. Have you noticed a decrease in A decrease in the ability to smell may be related to a dysfunction of cranial nerve I
your ability to smell or to taste? (olfactory) or a brain tumor. A decrease in the ability to taste may be related to
dysfunction of cranial nerves VII (facial) or IX (glossopharyngeal).
5. Have you experienced any ringing Ringing in the ears and decreased ability to hear may occur with dysfunction of cranial
in your ears or hearing loss? nerve VIII (acoustic).
6. Have you noticed any change in Changes in vision may occur with dysfunction of cranial nerve II (optic), increased
your vision? intracranial pressure, or brain tumors. Damage to cranial nerves III (oculomotor), IV
(trochlear), or VI (abducens) may cause double or blurred vision. Transient blind spots
may be an early sign of a cerebrovascular accident (CVA).
7. Do you have difficulty Injury to the cerebral cortex can impair the ability to speak or understand verbal
understanding when people are language.
talking to you? Do you have
difficulty making others
understand you? Do you have
 difficulty forming words
(dysarthria) or comprehending and
expressing your thoughts
(dysphasia)?
8. Do you experience difficulty Difficulty swallowing may relate to CVA, Parkinson’s disease, myasthenia gravis,
swallowing? Guillain-Barré syndrome, or dysfunction of cranial nerves IX (glossopharyngeal), X
(vagus), or XII (hypoglossal).
9. Have you lost bowel or bladder Loss of bowel control or urinary retention and bladder distention are seen with spinal
control or do you retain urine? cord injury or tumors.
10. Do you experience any memory Recent memory (24-hour memory) is often impaired in amnesic disorders, Korsakoff’s
loss? syndrome, delirium, and dementia. Remote memory (past dates and historical
accounts) may be impaired in cerebral cortex disorders.
11. Do you experience any repetitive Fasciculations (continuous, rapid twitching of resting muscles) may be seen in lower
involuntary trembling, quivering, motor neuron disease. Tremors (involuntary contraction of opposing groups of
shaking, or other movements? muscles) are typical in degenerative neurologic disorders, such as Parkinson’s
Describe. disease (3–6 per second while muscles are at rest or “pin rolling” between thumb and
opposing finger), or in cerebellar disease and multiple sclerosis (variable rate, and
especially with intentional movement).
Past Health History
1. Have you ever had any type of Head injuries, even if minor, can produce long-term neurologic deficits and affect the
head injury with or without loss of client’s level of functioning.
consciousness (e.g., sports injury,
auto accident, fall)? If so, describe
any physical or mental changes
that have occurred as a result.
What type of treatment did you
receive?
2. Have you ever had meningitis? These disorders can affect the long-term physical and mental status of the client.
3. Have you ever had encephalitis? These disorders can affect the long-term physical and mental status of the client.
4. Have you ever had injury to the These disorders can affect the long-term physical and mental status of the client.
spinal cord?
5. Have you ever had stroke? These disorders can affect the long-term physical and mental status of the client.
 6. Treatment received?
Family History
1. Do you have a family history of These disorders can affect the long-term physical and mental status of the client.
high blood pressure?
2. Do you have a family history of These disorders can affect the long-term physical and mental status of the client.
stroke?
3. Do you have a family history of These disorders can affect the long-term physical and mental status of the client.
Alzheimer disease?
4. Do you have a family history of These disorders can affect the long-term physical and mental status of the client.
epilepsy?
5. Do you have a family history of These disorders can affect the long-term physical and mental status of the client.
brain cancer?
6. Do you have a family history of These disorders can affect the long-term physical and mental status of the client.
Huntington chorea?
Lifestyle and Health Practices
1. Do you take any prescription or Prescription and nonprescription drugs can cause various neurologic symptoms such
nonprescription medications? as tremors or dizziness, altered level of consciousness, decreased response times,
and changes in mood and temperament.
2. Do you smoke? Nicotine, which is found in cigarettes, constricts the blood vessels, which decreases
blood flow to the brain. Cigarette smoking is a risk factor for CVA
3. Do you wear your seat belt when Seat belts and protective headgear can prevent head injury.
riding in vehicles? Do you wear
protective headgear when riding a
bicycle or playing sports?
4. Describe your usual daily diet. Peripheral neuropathy can result from a deficiency in niacin, folic acid, or vitamin B12.
5. Have you ever had prolonged Prolonged exposure to these substances can alter neurologic status.
exposure to lead, insecticides,
pollutants, or other chemicals?
6. Do you frequently lift heavy Intervertebral disc injuries may result when heavy objects are lifted improperly.
objects?
7. Do you frequently perform Peripheral nerve injuries can occur from repetitive movements.
repetitive motions?
8. Can you perform your normal Neurologic symptoms and disorders often negatively affect the ability to perform
activities of daily living? ADLs.
Physical Assessment Guide to Collect Objective Client Data
Current Symptoms Rationale
1. Gather Equipment To save time and effort.
And to be organize.
2. Explain the procedure to To gain consent.
the client.
3. Ask the client to put on For the client to be more
gown. comfortable
Mental Status Normal Findings Abnormal Findings
1. Observe the client’s Client is alert and oriented Client is not alert to person, place, day or time; Does not respond
level of consciousness. to what is happening at appropriately.
the time of the interview
and physical assessment
Responds to your
questions and interacts
appropriately
2. Observe appearance Dress is appropriate for Unusually meticulous grooming and finicky mannerisms may be
and behaviour. occasion and weather. seen in obsessivecompulsive disorder. Poor hygiene and
Client is cooperative and inappropriate dress may be seen with organic brain syndrome.
purposeful in his or her Uncooperative, bizarre behavior may be seen in the angry, mentally
interactions with others. ill, or violent client. Anxious clients are often fidgety and restless.
Affect is appropriate for
the client’s situation.
3. Observe mood, feelings, Cooperative or friendly, Flat affect, euphoria, anxiety, fear, ambivalence, irritability,
and expressions expresses feelings depression, and/or rage are all examples of altered mood
appropriate to situation, expressions. Depression, anxiety, and somatization are common
verbalizes positive mental disorders seen in at least 5% to 10%
feelings regarding others
and the future, expresses
positive coping
mechanisms (support
groups, exercise, sports,
hobbies, counseling).
4. Observe thought Client expresses full, free- bnormal processes include persistent repetition of ideas, illogical
processes and flowing thoughts; follows thoughts, interruption of ideas, invention of words, or repetition of
perceptions. directions accurately; phrases, as in schizophrenia; rapid flight of ideas, repetition of ideas,
expresses realistic and use of rhymes and punning, as in manic phases of bipolar
perceptions; is easy to disorder.
understand and makes
sense; does not voice
suicidal thoughts.
5. Observe Cognitive
Abilities.

a. Assess orientation. a. Client is aware of a. Reduced degree of orientation may be seen with organic
Ask for the client’s self, others, time, brain disorders or psychiatric illness such as withdrawal from
name and names of home address, and chronic alcohol use or schizophrenia.
family members current location.
(person), the time
such as hour, day,
date, or season
(time), and where the
client lives or is now
(place)

b. Assess b. Client listens and b. Distraction and inability to focus on task at hand are noted in
concentration. can follow anxiety, fatigue, attention deficit disorders, and impaired
directions without states due to alcohol or drug intoxication.
Note the client’s difficulty.
ability to focus and
stay attentive to you
during the interview
and examination.
Give the client
directions such as
 “Please pick up the
pencil with your left
hand, place it in your
right hand, then hand
it to me.”

c. Assess recent c. Inability to recall recent events is seen in delirium, dementia,

memory. Ask the c. Recalls recent depression, and anxiety.
client “What did you events without
have to eat today?” difficulty.
or “What is the
weather like today?”
Cranial Nerves (CN)
1. Test CN I (olfactory). Client correctly identifies Inability to smell (neurogenic anosmia) or identify the correct scent
scent presented to each may indicate olfactory tract lesion or tumor or lesion of the frontal
nostril. lobe. Loss of smell may also be congenital or due to other causes
such as nasal or sinus problems. It may also be caused by injury of
nerve tissue at the top of the nose or the higher smell pathways in
the brain due to viral upper respiratory infection. Smoking and use of
cocaine may also impair one’s sense of smell.
2. Test CN II (optic).

a. Use a Snellen chart to a. Client has 20/20 a. Abnormal findings include difficulty reading Snellen chart,
assess vision in each vision OD (right missing letters, and squinting.
eye eye) and OS (left
eye).

b. Client reads print by holding closer than 14 inches or holds

b. Ask the client to read a b. Client reads print at print farther away as in presbyopia, which occurs with aging.
newspaper or magazine 14 inches without
paragraph to assess difficulty.
near vision.
 c. Loss of visual fields may be seen in retinal damage or
c. Assess visual fields of c. Full visual fields detachment, with lesions of the optic nerve, or with lesions of
each eye by the parietal cortex.
confrontation.

d. Use an ophthalmoscope d. Round red reflex is d. Papilledema (swelling of the optic nerve) results in blurred
to view the retina and present, optic disc optic disc margins and dilated, pulsating veins.
optic disc of each eye is 1.5 mm, round or
slightly oval, well-
defined margins,
creamy pink with
paler physiologic
cup. Retina is pink.
3. Assess CN III
(oculomotor), IV
(trochlear), and VI
(abducens)

a. Inspect margins of the a. Eyelid covers about a. Ptosis (drooping of the eyelid) is seen with weak eye muscles
eyelids of each eye. 2 mm of the iris. such as in myasthenia gravis.

b. Assess extraocular b. Eyes move in a b. Eyes move in a smooth, coordinated motion in all directions
movements. If smooth, (the six cardinal fields).
nystagmus is noted, coordinated motion
determine the direction in all directions (the
of the fast and slow six cardinal fields).
phases of movement.

c. Assess pupillary c. Bilateral illuminated c. Some abnormalities are dilated pupils, Argyll Robertson
response to light (direct pupils constrict pupils, constricted fixed pupils, unilaterally dilated pupil,
 and indirect) and simultaneously. constricted pupil, bilateral muscle weakness, and unilateral
accommodation in both Pupil opposite the muscle weakness.
eyes. one illuminated
constricts
simultaneously.
4. Assess CN V
(trigeminal).
a. Temporal and a. Decreased contraction in one of both sides. Asymmetric
a. Test motor function. masseter muscles strength in moving the jaw may be seen with lesion or injury
Ask the client to clench contract bilaterally. of the 5th cranial nerve.
the teeth while you
palpate the temporal and
masseter muscles for
contraction

b. Test sensory function. b. The client correctly b. Inability to feel and correctly identify facial stimuli occurs with
Tell the client: “I am identifies sharp and lesions of the trigeminal nerve or lesions in the spinothalamic
going to touch your dull stimuli and light tract or posterior columns.
forehead, cheeks, and touch to the
chin with the sharp or forehead, cheeks,
dull side of this paper and chin.
clip. Please close your
eyes and tell me if you
feel a sharp or dull
sensation. Also tell me
where you feel it”.
Repeat test for light
touch with a wisp of
cotton.

c. Test corneal reflex. Ask c. Eyelids blink c. An absent corneal reflex may be noted with lesions of the
the client to look away bilaterally. trigeminal nerve or lesions of the motor part of cranial nerve
 and up while you lightly VII (facial).
touch the cornea with a
fine wisp of cotton.
5. Test CN VII (facial).

Test motor function. Ask the Client smiles, frowns, Inability to close eyes, wrinkle forehead, or raise forehead along with
client to: wrinkles forehead, shows paralysis of the lower part of the face on the affected side is seen
 Smile teeth, puffs out cheeks, with Bell’s palsy (a peripheral injury to cranial nerve VII [facial]).
 Frown and wrinkle purses lips, raises Paralysis of the lower part of the face on the opposite side affected
forehead eyebrows, and closes may be seen with a central lesion that affects the upper motor
 Show teeth eyes against resistance. neurons, such as from stroke.
 Puff out cheeks Movements are
 Purse lips symmetric.
 Raise eyebrows
 Close eyes tightly
against resistance
6. Test CN VIII
(acoustic/vestibulocochl
ear).

Test the client’s hearing Client hears whispered Vibratory sound lateralizes to good ear in sensorineural loss. Air
ability in each ear and words from 1–2 feet. conduction is longer than bone conduction, but not twice as long, in
perform the Weber and Weber test: Vibration a sensorineural loss
Rinne tests to assess the heard equally well in both
cochlear (auditory) ears. Rinne test: AC > BC
component of cranial nerve (air conduction is twice as
VIII long as bone conduction).
7. Test CN IX
(glossopharyngeal) and
X (vagus).

a. Test motor function. a. Uvula and soft a. Soft palate does not rise with bilateral lesions of cranial nerve
 Ask the client to open palate rise X (vagus). Unilateral rising of the soft palate and deviation of
mouth wide and say “ah” bilaterally and the uvula to the normal side are seen with a unilateral lesion
while you use a tongue symmetrically on of cranial nerve X (vagus).
depressor on the client’s phonation.
tongue.

b. Test the gag reflex by

touching the posterior b. Gag reflex intact. b. An absent gag reflex may be seen with lesions of cranial
pharynx with the tongue Some normal nerve IX (glossopharyngeal) or X (vagus).
depressor. clients may have a
reduced or absent
c. Check the client’s gag reflex.
ability to swallow by c. Dysphagia or hoarseness may indicate a lesion of cranial
giving the client a drink c. Client swallows nerve IX (glossopharyngeal) or X (vagus) or other neurologic
of water. Also note the without difficulty. disorder.
client’s voice quality No hoarseness
noted.
8. Test CN XI (spinal
accessory).

a. Ask the client to shrug a. There is a. Asymmetric muscle contraction or drooping of the shoulder
the shoulders against symmetric, strong may be seen with paralysis or muscle weakness due to neck
resistance to assess the contraction of the injury or torticollis.
trapezius muscle. trapezius muscles.

b. Ask the client to turn the

head against resistance, b. There is strong b. Atrophy with fasciculations may be seen with peripheral
first to the right then to contraction of nerve disease.
the left, to assess the sternocleidomastoi
sternocleidomastoid d muscle on the
muscle. side opposite the
turned face.
 9. Test CN XII
(hypoglossal).

To assess strength and Tongue movement is Fasciculations and atrophy of the tongue may be seen with
mobility of the tongue, ask symmetric and smooth, peripheral nerve disease. Deviation to the affected side is seen with
the client to protrude and bilateral strength is a unilateral lesion.
tongue, move it to each side apparent.
against the resistance of a
tongue depressor, and then
put it back in the mouth.
Motor and Cerebellar System
1. Test condition and Muscles are fully Muscle atrophy may be seen in diseases of the lower motor neurons
movement of muscles. developed and symmetric or muscle disorders.
in size (bilateral sides may
vary 1 cm from each
other).
2. Test balance.

a. Evaluate gait and a. Gait is steady; a. Gait and balance can be affected by disorders of the motor,
balance. To assess gait opposite arm sensory, vestibular, and cerebellar systems.
and balance, ask the swings.
client to walk naturally
across the room. Note
posture, freedom of
movement, symmetry,
rhythm, and balance.

b. Ask the client to walk in b. An uncoordinated or unsteady gait that did not appear with
heel-to-toe fashion, next b. Client maintains the client’s normal walking may become apparent with
on the heels, then on the balance with tandem walking or when walking on heels and toes.
toes. Demonstrate the tandem walking.
walk first; then stand Walks on heels and
 close by in case the toes with little
client loses balance. difficulty.

c. Perform the Romberg c. Client stands erect c. Positive Romberg test: Swaying and moving feet apart to
test. Ask the client to with minimal prevent fall is seen with disease of the posterior columns,
stand erect with arms at swaying, with eyes vestibular dysfunction, or cerebellar disorders.
side and feet together. both open and
Note any unsteadiness closed.
or swaying. Then with
the client in the same
body position, ask the
client to close the eyes
for 20 seconds. Again
note any imbalance or
swaying.

d. Now ask the client to d. Bends knee while d. Inability to stand or hop on one foot is seen with muscle
stand on one foot and to standing on one weakness or disease of the cerebellum.
bend the knee of the leg foot; hops on each
the client is standing on foot without losing
(Fig. 25-19). Then ask balance.
the client to hop on that
foot. Repeat on the other
foot.
3. Assess coordination.

Demonstrate the finger-to- Client touches finger to Uncoordinated, jerky movements and inability to touch the nose may
nose test to assess nose with smooth, be seen with cerebellar disease.
accuracy of movements, accurate movements, with
then ask the client to extend little hesitation.
and hold arms out to the
side with eyes open. Next,
 say, “Touch the tip of your
nose first with your right
index finger, then with your
left index finger. Repeat this
three times” (Fig. 25-20).
Next, ask the client to
repeat these movements
with eyes closed.
Sensory System
1. Assess light touch, pain, Client correctly Client reports: anesthesia, hypesthesia, hyperesthesia, analgesia,
and temperature differentiates between dull hypalgesia, and hyperalgesia.
sensations and sharp sensations and
hot and cold temperatures
a. To test light touch over various body parts.
sensation, use a wisp of
cotton to touch the client

b. To test pain sensation,

use the blunt and sharp
ends of a safety pin or
paper clip.

c. To test temperature
sensation, use test tubes
filled with hot and cold
water.
2. Test vibratory sensation.

Strike a lowpitched tuning fork Client correctly identifies Inability to sense vibrations may be seen in posterior column disease
on the heel of your hand and sensation or peripheral neuropathy.
hold the base on the distal
radius, forefinger tip, medial
malleolus, and, last, the tip of
the great toe.
3. Test sensitivity to
position.

Ask the client to close both Client correctly identifies Inability to identify the directions of the movements may be seen in
eyes. Then hold the client’s toe directions of movements. posterior column disease or peripheral neuropathy.
or a finger on the lateral sides
and move it up or down . Ask
the client to tell you the
direction it is moved. Repeat on
the other side
4. Assess tactile
discrimination (fine
touch).

Remember that the client Client correctly identifies Inability to correctly identify objects, area touched, number written in
should have eyes closed. To object. hand; to discriminate between two points; or identify areas
test stereognosis, place a simultaneously touched may be seen in lesions of the sensory cortex
familiar object such as a
quarter, paper clip, or key in the
client’s hand and ask the client
to identify it. Repeat with
another object in the other
hand.
Reflexes
1.

a. Test deep tendon a. Normal reflex a. Absent or markedly decreased (hyporeflexia) deep tendon
reflexes. scores range from reflexes (rated 0) occur when a component of the lower motor
1+ (present but neurons or reflex arc is impaired; this may be seen with spinal
decreased) to 2+ cord injuries. Markedly hyperactive (hyperreflexia) deep
 (normal) to 3+ tendon reflexes (rated 4+) may be seen with lesions of the
(increased or brisk, upper motor neurons and when the higher cortical levels are
but not pathologic). impaired.

b. Test biceps reflex. b. Elbow flexes and b. No response or an exaggerated response is abnormal
contraction of the
biceps muscle is
seen or felt.
Ranges from 1+ to
3+. Forearm flexes
and supinates.
Ranges from 1+ to
3+.

c. Assess brachioradialis c. Elbow extends, c. No response or an exaggerated response is abnormal.

reflex. triceps contracts.
Ranges from 1+ to
3+.
d. Test triceps reflex.
d. Knee extends d. No response or exaggerated response.
quadriceps muscle
contracts. Ranges
from 1+ to 3+.
e. Assess patellar reflex
e. Normal response is e. No response or an exaggerated response is abnormal.
plantarflexion of the
foot. Ranges from
1+ to 3+.

f. Test Achilles reflex. f. In some older f. No response or an exaggerated response is abnormal.

 clients, the Achilles
reflex may be
absent or difficult to
elicit.

g. Test ankle clonus g. No rapid g. Repeated rapid contractions or oscillations of the ankle and
contractions or calf muscle are seen with lesions of the upper motor neurons.
oscillations (clonus)
of the ankle are
elicited.
2. Test superficial reflexes.

a. Assess plantar reflex. a. Flexion of the toes a. The toes will fan out for abnormal (positive Babinski
occurs. response).

b. Test abdominal reflex. b. Abdominal muscles

contract; the b. Superficial reflexes may be absent with lower or upper motor
umbilicus deviates neuron lesions.
toward the side
being stimulated.
c. Test cremasteric reflex
in male clients c. Scrotum elevates c. Absence of reflex may indicate motor neuron disorder.
on stimulated side.
3. Tests for Meningeal
Irritation or Inflammation.

a. Test for Brudzinski’s a. Hips and knees a. Pain and flexion of the hips and knees are positive
sign. remain relaxed and Brudzinski’s signs, suggesting meningeal inflammation.
motionless

b. Test for Kernig’s sign. b. No pain is felt. b. ain and increased resistance to extending the knee are a
 Discomfort behind positive Kernig’s sign. When Kernig’s sign is bilateral, the
the knee during full examiner suspects meningeal irritation.
extension occurs in
many normal
people.
Analysis of Data
1. Formulate nursing
diagnoses (wellness,
risk, actual).
2. Formulate collaborative
problems.
3. Make necessary
referrals.