Chapter 36 Introduction to the Nervous System

The nurse is assessing the client's pupils following a sports injury. Which assessment finding(s) indicates a neurologic concern? Select all that apply.

-Unequal pupils -Pinpoint pupils -Absence of pupillary response

The nurse is caring for a client who is undergoing single-photon emission computed tomography (SPECT). What is a potential side effect that this client may suffer?

Allergic reaction to the imaging material

A client presents to the emergency department status post-seizure. The health care provider wants to measure CSF pressure. What test might be ordered on this client?

Lumbar puncture

Which neurons transmit impulses from the CNS?

Motor

The nurse collects neurologic data and determines that the client has significant visual deficits. A brain tumor is considered. Which area of the brain does the nurse consider to be most likely to contain the neurologic deficit?

Occipital

A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture?

Position the client flat as directed.

The nurse collects data regarding a client's ability to detect sensation in the upper extremity. Which nursing action(s) is appropriate? Select all that apply.

-Place a warm cotton ball on the client's arm. -Use a safety pin to stroke the client's fingers. -Drag a tube filled with cold water on the client's arm. -Place a tube filled with warm water on the client's hand.

A client undergoes a scheduled electroencephalogram (EEG). Which post-procedure activity is most appropriate?

Allow the client to wash hair and rest.

The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?

Moving the head and chin toward the chest

A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult that is slowing transmission of the motor neurons, in what would the nurse anticipate a delayed reaction?

Response due to interrupted impulses from the central nervous system

The nurse is assessing the assigned client's level of consciousness during morning rounds. The nurse speaks the client's name, strokes the client's hand, and moves the client's shoulder. There is a delay, and then the client states, "What do you want?" Which level of consciousness should the nurse document?

Somnolent

The nurse is caring for a client with a significant allergy history to various medications and shellfish. Because the client needs to have a diagnostic study with contrast, which medication classification is anticipated?

Antihistamine

The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm?

Cerebral angiography

A nurse is working in a neurologist's office. The physician orders a Romberg test. What should the nurse instruct the client to do?

Close eyes and stand erect.

Which diagnostic procedure would the nurse anticipate performing first if the goal was to obtain a thin "slice" of a muscular body area?

Computed tomography (CT)

The nurse provides care for a client with a deteriorating neurologic status. The nurse collects data at the beginning of the shift that reveals a falling blood pressure (BP) and heart rate (HR), and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate?

Flaccidity

A nurse is noting from a client's neurologic assessment findings that the client's motor impulses are interrupted from the brain to the spinal cord. It also appears that the client lacks sensory impulses from the peripheral sensory neurons to the brain. Which area has the deficit?

Medulla oblongata

The nurse provides care for a client who is comatose and needs to collect motor response data. Which nursing action is appropriate?

Observing the client's response to painful stimuli

The nurse assists the health care provider (HCP) in completing a lumbar puncture (LP). Which should the nurse note as a concern?

The cerebrospinal fluid (CSF) is cloudy in nature.

A critical care nurse is documenting the assessment of a client. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. This means that the client:

is not responding to stimuli.

A nurse is working in an outpatient studies unit administering neurological tests. The client is surprised that paste is used to secure an electroencephalogram and asks how it will be removed from the hair. With what substance does the nurse reply?

shampoo

The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve?

Cranial nerve XII

The nurse scores the client's level of consciousness (LOC) using the Glasgow Coma Scale. Which score should indicate to the nurse that the client needs emergency attention?

a score of 9

A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects in the body systems, what does the nurse anticipate the liver will do?

Convert glycogen to glucose for immediate use.

The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse should respond by describing the action of the:

sympathetic nervous system.

The critical care nurse is giving end-of-shift report on a client. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate?

Comatose

The nurse is caring for a client in the emergency department with a diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the client's face and torso. Which action by the nurse aide would prompt the nurse to provide further instruction?

Moving the client's head to clean behind the ears.

The nurse is caring for a client newly diagnosed with multiple sclerosis who is overwhelmed by learning about the disease. The client indicates understanding that there is a disruption in the covering of axons but does not remember what the covering is called. What should the nurse tell the client?

That the covering is called myelin and that it can be discussed further at the next meeting.

The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of which cranial nerve?

VIII