Chapter 55
Which part of the central nervous system carries specific sensory information to higher levels of the central nervous system?
Ascending tracts The ascending tracts carry specific sensory information to higher levels of the central nervous system. The reflex arc in the spinal cord plays an important role in maintaining muscle tone. Descending tracts carry impulses that are responsible for muscle movement. Descending motor tracts influence the skeletal muscle through lower motor neurons.
Which patient is likely to have an inability to sense taste, as identified by the nurse during assessment of a group of four patients?
B The facial nerve innervates the facial and cheek muscles and regulates the taste in the anterior two-thirds of the tongue. Damage to the nerve, which Patient B has, can result in an inability to sense taste. Patient A has a damaged optic nerve, and the optic nerve transmits visual information from the retina of eyes to the vision centers of the brain. Patient C has a damaged olfactory nerve, which transmits impulses that convey the sense of smell. Patient D has a damaged oculomotor nerve, which controls eye movements.
The nurse is obtaining a health history from a patient reporting memory loss and dizziness. With which neurologic component does the nurse document that these findings correlate?
Cognitive perceptual A patient's subjective report of memory loss and dizziness belongs to the cognitive perceptual assessment portion of a health history. Activity exercise is an assessment of the patient's physical coordination and activity. Health perception-health management includes assessment of a patient's health history and habits. Assessment of the patient's self-perception self-concept explores the patient's emotional state.
What cells constitute almost half the brain and spinal cord mass?
Glial cells Glial cells provide support, protection, and nourishment to neurons and constitute almost half the brain and spinal cord mass. Schwann cells myelinate the nerve fibers in the periphery. Neurotransmitters are chemicals that affect the transmission of impulses across the synaptic cleft. Neurons are one of the two types of cells that make up the nervous system and are supportive of glial cells.
When assessing motor function of a patient admitted with a stroke, the nurse identifies mild weakness of the arm demonstrated by downward drifting of the arm. How should the nurse most accurately document this finding?
Pronator drift Downward drifting of the arm or pronation of the palm is identified as a pronator drift. Athetosis is a slow, writhing, involuntary movement of the extremities. Hypotonia is flaccid muscle tone, and hemiparesis is weakness of one side of the body. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.
An extensor plantar response is associated with which nervous system abnormality?
Upper motor neuron lesions An upper motor neuron lesion results in an extensor plantar response in which the toes point up with plantar stimulation. Lesions in the sensory cortex result in paresthesia or an alteration in sensation. A brainstem lesion is characterized by ophthalmoplegia, which presents as paralysis of the eye muscles. Lower motor neuron lesions are characterized by diminished or absent motor responses.
The nurse is assessing a patient with a recent stroke and observes that they do not appear to understand spoken words. What part of the cerebrum does the nurse recognize is damaged?
Wernicke's area Wernicke's area of the cerebrum is involved in the integration of auditory language and understanding of spoken words. Broca's area regulates the verbal expression. The parietal lobe integrates somatic and sensory output. The superior temporal gyrus registers the auditory input.
When assessing a patient with a traumatic brain injury, the nurse notes uncoordinated movement of the extremities. How should the nurse document this assessment?
Ataxia Ataxia is a lack of coordination of movement, possibly caused by lesions of sensory or motor pathways, cerebellum disorders, or certain medications. Apraxia is the inability to perform learned movements despite having the desire and physical ability to perform them related to a cerebral cortex lesion. Anisocoria is inequality of pupil size from an optic nerve injury. Anosognosia is the inability to recognize a bodily defect or disease related to lesions in the right parietal cortex.
The nurse is demonstrating neurologic assessment techniques to a student nurse for an older adult patient. What statement by the student nurse demonstrates further instruction is required?
"Decreased oxygen supply results in a decreased risk of postural hypotension." In older patients, a decreased blood flow rate can cause decreased oxygen supply to the brain, resulting in increased postural hypotension during change of position. In older patients, an assessment of deep tendon reflexes usually reveals an average reflex score. Diminished strength and agility occurs due to decreased muscle bulk in older patients. Disturbances of sleep pattern occur in older patients due to modification of hypothalamic function.
A patient reports decreased libido. Which part of the cerebrum has the potential for impaired functioning?
Limbic system The limbic system is located near the inner surfaces of the cerebral hemispheres and controls the sexual response and emotions. Impaired functioning of the limbic system may decrease libido. The thalamus relays the sensory and motor input to and from the cerebrum. The basal ganglia control and facilitate learned and automatic movements. The hypothalamus regulates endocrine and autonomic functions.
Which diagnostic study is used to obtain cerebral spinal fluid (CSF)?
Lumbar puncture CSF is obtained via lumbar puncture. A PET scan measures metabolic activity of the brain to assess cellular death or damage. A transcranial Doppler is used to evaluate blood flow of the intracranial blood vessels. A CT scan provides radiographic images of the brain. Test-Taking Tip: Begin studying two to three months in advance. Schedule study time each day. Set up a study schedule of topics.
To test the function of the optic nerve (CN II), the nurse often uses a Snellen chart. If a Snellen chart is not available, what can the nurse use for this assessment?
Magazine or newspaper To test the function of the optic nerve (CN II), the nurse tests the visual acuity. If a Snellen chart is not available, asking the patient to read from a magazine or newspaper will give a gross assessment of acuity. The Amsler grid is used to detect macular degeneration. The ophthalmoscope is an instrument that is used for inspection of vessels and structures within the eye. STUDY TIP: Laughter is a great stress reliever. Watching a short program that makes you laugh, reading something funny, or sharing humor with friends helps decrease stress.
What is the rating on the muscle response scale of 0 to 5 when an elicited patellar reflex is brisk?
3 A patellar reflex that is brisk is rated a 3. A rating of a 0 is an absent reflex, and a 2 is a normal response. A muscle response rated a 5 is hyperreflexic with sustained clonus.
Which neurotransmitters inhibit the transmission of impulses across the synaptic cleft? Select all that apply.
-GABA -Serotonin -Dopamine GABA, serotonin, and dopamine are neurotransmitters that inhibit the transmission of impulses across the synaptic cleft. Endorphins block pain transmission. Glutamate and epinephrine are excitatory neurotransmitters that activate postsynaptic receptors that increase the likelihood that an action potential will be generated.
Which are components of the central nervous system (CNS)? Select all that apply.
-Cerebrum -Brainstem -Spinal cord -Cerebellum The CNS is made up of the cerebrum (right and left hemispheres), cerebellum, brainstem, and spinal cord. The spinal and cranial nerves are parts of the peripheral nervous system.
The nurse educator is teaching a group of nursing students about the anatomy and physiology of the nervous system. The educator asks which glial cells are most abundant, primarily found in the gray matter, and provide structural support to neurons. Which response is correct?
"Astrocytes" Astrocytes are the most abundant glial cells. They are found primarily in the gray matter and provide structural support to neurons. Astrocytes are macroglial cells. The delicate processes of astrocytes form the blood-brain barrier with the endothelium of the blood vessels. Microglial cells are specialized macrophages capable of phagocytosis. Ependymal cells line the ventricles of the brain and help in the secretion of cerebrospinal fluid. Oligodendrocytes are specialized cells that produce the myelin sheath in the central nervous system; they are mainly found in the white matter of the brain. Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer.
The nurse provides instructions to a patient who is scheduled for an electroencephalogram (EEG) the following day. What statement made by the patient indicates an understanding of the instructions?
"I'll wash my hair tonight." The patient's hair should be free of oils, sprays, and lotions before an EEG. Oily hair or hair care products may interfere with the conduction of neurologic electrical impulses recorded during an EEG. Therefore patient preparation includes shampooing the hair and refraining from using any other hair products. Taking a laxative, going to bed early, and refraining from eating or drinking after midnight are not required before an EEG.
The nurse is educating the patient who is scheduled for an electromyography (EMG). What information should the nurse provide to the patient?
"You will be asked to tighten certain muscles for electrical measurement." An EMG is the recording of electrical activity associated with innervation of skeletal muscles. Needle electrodes are inserted into the muscle to record electrical activity with muscle contraction. Because muscles at rest show no electrical activity, the patient will be asked to tighten (contract) muscle groups to record electrical activity. The patient must be awake to cooperate with this examination. Electrical stimuli are not applied to the muscles for this test. No patches will be applied to the skin.
The nurse is assessing the patient's accessory nerve. Which instructions should the nurse give to the patient? Select all that apply.
-"Shrug your shoulders." -"Turn your head against resistance to either side." The accessory nerve controls the sternocleidomastoid and trapezius muscles that aid in head rotation, shoulder elevation, and abduction of the arm. Therefore, while assessing the patient's accessory nerve, the nurse should ask the patient to shrug the shoulders and turn the head to either side against resistance. The nurse should ask the patient to protrude the tongue while assessing olfactory nerve function. The nurse should ask the patient to read the Snellen chart to assess optic nerve function. The nurse should ask the patient to close the eyes tightly while assessing facial nerve function. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation.
A nurse is assessing the mental status of a patient. By what criteria should the nurse judge the mental status of the patient? Select all that apply.
-Alert and oriented -Appropriate mood and affect The patient's alertness and orientation along with appropriate mood and affect help the nurse assess the mental status of the patient. An intact sense of smell, reaction of pupils to light, and a midline protrusion of the tongue suggest normal functioning of associated cranial nerves.
The nurse is performing a neurologic assessment for a patient. When assessing proprioception, what will the nurse have the patient do? Select all that apply
-Ask the patient to stand with feet together and then close his or her eyes -Ask the patient the position of the big toe after moving it up and down with the patient's eyes closed Proprioception is the individual's ability to perceive the position of a body part with his or her eyes closed. The individual should be able to replicate the position of the body part accurately with the opposite extremity or describe the position verbally. A Romberg test is the test for proprioception. The patient is asked to stand with the feet together and then close his or her eyes. If the patient is able to maintain balance with the eyes open but sways or falls with the eyes closed (i.e., a positive Romberg test), vestibulocochlear dysfunction or disease in the posterior columns of the spinal cord may be indicated. Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care.
The nurse is performing a neurologic assessment for a patient. When assessing proprioception, what will the nurse have the patient do? Select all that apply.
-Ask the patient to stand with feet together and then close his or her eyes. -Ask the patient the position of the big toe after moving it up and down with the patient's eyes closed. Proprioception is the individual's ability to perceive the position of a body part with his or her eyes closed. The individual should be able to replicate the position of the body part accurately with the opposite extremity or describe the position verbally. A Romberg test is the test for proprioception. The patient is asked to stand with the feet together and then close his or her eyes. If the patient is able to maintain balance with the eyes open but sways or falls with the eyes closed (i.e., a positive Romberg test), vestibulocochlear dysfunction or disease in the posterior columns of the spinal cord may be indicated. Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care.
The health care provider requests cerebral angiography for a patient to detect a potential brain tumor. What should the nurse ensure before the patient goes for the test? Select all that apply.
-Assess the patient for stroke -Instruct that a contrast medium will be injected Cerebral angiography is a contrast-based test. The nurse should assess the patient for stroke before the test, because any thrombi, if present, may be dislodged during the procedure. The nurse should explain that a contrast medium will be injected by a small needle into the vein, making this procedure invasive. The patient is asked to empty the bladder before the procedure. The preceding meal should be withheld to prevent aspiration if an adverse reaction to the contrast medium occurs.
A nurse is assessing the mental function of a patient with a neurologic disorder. What assessment findings would the nurse recognize should be reported to the primary care provider? Select all that apply.
-Attention is fleeting -Patient is overtalkative Fleeting attention and overtalkativeness imply a disturbance in mental status. If the patient is well-groomed and sits comfortably, this indicates that the patient is aware of his or her appearance and behavior. An easy flow of conversation indicates that the patient can communicate well.
A nurse tests the bicep reflex in a patient. What reaction does the nurse document as a normal response? Select all that apply.
-Contraction of biceps muscle -Flexion of the arm at the elbow The bicep reflex is elicited with the patient's arm partially flexed and palm up, by placing the nurses' thumb over the biceps tendon in the antecubital space and striking the thumb with a hammer. The normal response is flexion of the arm at the elbow or contraction of the biceps muscle that can be felt by the thumb. Clonus is an abnormal response characterized by a continued rhythmic contraction of the muscle with continuous application of the stimulus. Extension of the arm at the elbow and relaxation of the biceps muscle on the biceps test are abnormal responses and indicate a dysfunctional neurologic system. Test-Taking Tip: Avoid spending excessive time on any one question. Most questions can be answered in one to two minutes.
What are the functions of the area depicted in the figure? Select all that apply.
-Coordinating voluntary movement -Maintaining trunk stability and equilibrium The part labeled A in the figure is the cerebellum. The cerebellum is located in the posterior part of the cranial fossa inferior to the occipital lobe. An important function of cerebellum is to coordinate voluntary movement and maintain trunk stability and equilibrium. The hypothalamus regulates the endocrine system. The reticular activating system (RAS) regulates arousal and sleep-wake transitions. The brain stem controls coughing, hiccupping, and sneezing response.
During a neurologic assessment, the nurse tests the functionality of the facial nerve. What instructions should the nurse give to the patient? Select all that apply.
-Frown -Raise the eyebrows Asymmetry in facial movements indicates damage to the facial nerve. When assessing cranial nerve VII (the facial nerve), the patient is asked to raise the eyebrows and frown and may also be asked to close the eyes tightly or purse the lips. A Snellen chart is used to test visual acuity, and protrusion of the tongue or moving the tongue from side to side assesses the hypoglossal nerve.
The nurse is assessing a patient's facial nerve (CN VII) integrity. What should the nurse ask the patient to do? Select all that apply.
-Raise eyebrows -Purse lips together -Close eyes tightly To assess the motor function of the facial nerve (CN VII), assessments include asking the patient to raise eyebrows, close eyes tightly, purse the lips, perform an exaggerated smile, and frown. The nurse is looking for any asymmetry in facial movements. Clenching the teeth while palpating the masseter muscles is an assessment check for the trigeminal nerve (CN V). Extending the tongue assesses the hypoglossal nerve (CN XII). Asking the patient to say "ga, ga, ga" requires movement of the pharynx and tongue, thereby assessing cranial nerve IX, the glossopharyngeal. Test-Taking Tip: Become familiar with reading questions on a computer screen. Familiarity reduces anxiety and decreases errors.
A nurse is caring for a patient with a suspected accessory nerve injury. What instructions will the nurse give to the patient to test the functions of this nerve? Select all that apply.
-Shrug the shoulders -Turn the head to either side against resistance The accessory nerve controls the functions of the sternocleidomastoid and trapezius muscles. It is tested by asking the patient to shrug the shoulders and turn the head to either side against resistance. There should be smooth contraction of the sternocleidomastoid and trapezius muscles. The gag reflex is elicited to test the glossopharyngeal and vagus nerves. When testing the hypoglossal nerve, the patient is asked to move the tongue up and down and side to side and to push the tongue to either side against resistance.
A patient presents with an inability to turn the eyes together in the same direction. Which nerves should be tested to detect paralysis of the eye muscle in this patient? Select all that apply.
-Trochlear nerve -Abducens nerve -Oculomotor nerve The trochlear, oculomotor, and abducens nerves help in movements of the eyes. Therefore these three nerves should be tested together by asking the patient to hold the head steady and follow the movement of the nurse's finger with the eyes only. A normal response is parallel tracking of an object with both eyes. The optic nerve, hypoglossal nerve, and olfactory nerve do not play a role in eye movements. STUDY TIP: Record the information you find to be most difficult to remember on 3" × 5" cards and carry them with you in your pocket or purse. When you are waiting in traffic or for an appointment, just pull out the cards and review again. This "found" time may add points to your test scores that you have lost in the past.
When performing a physical examination on a patient with a suspected motor system disorder, what manifestations is the nurse likely to find? Select all that apply.
-Unsteady gait -Positive Romberg test -Inability to perform finger-nose test During assessment of the motor system, findings such as a normal gait and station, a negative Romberg test, and a smooth performance of the finger-nose test are essential to confirm normal functioning of the motor nerves. An asymmetric smile, full facial movements, and nystagmus are associated with assessment of the cranial nerves.
When performing a physical examination on a patient with a suspected motor system disorder, what manifestations is the nurse likely to find? Select all that apply
-Unsteady gait During assessment of the motor system, findings such as a normal gait and station, a negative Romberg test, and a smooth performance of the finger-nose test are essential to confirm normal functioning of the motor nerves. An asymmetric smile, full facial movements, and nystagmus are associated with assessment of the cranial nerves.
When performing a cranial nerve assessment on a patient, the nurse tickles the back of the pharynx and notes the contraction of the surrounding muscles. This procedure helps in testing the function of which nerves? Select all that apply.
-Vagus nerve -Glossopharyngeal nerve Stimulating the pharynx helps to assess the glossopharyngeal and vagus nerves; these nerves are tested together because both stimulate the pharynx. The hypoglossal nerve is tested by asking the patient to protrude the tongue. The facial nerve is tested by asking the patient to raise the eyebrows, close the eyes tightly, purse the lips, draw back the corners of the mouth in an exaggerated smile, and frown. The accessory nerve is tested by asking the patient to shrug the shoulders and turn the head to either side against resistance.
A nurse elicits the gag reflex in a patient. Which cranial nerve is the nurse assessing with this technique? Select all that apply.
-Vagus nerve -Glossopharyngeal nerve The gag reflex tests the performance of the motor component of the vagus nerve and the sensory component of the glossopharyngeal nerve. The test is performed by touching the sides of the posterior pharynx or soft palate with a tongue blade. The olfactory nerve is assessed by asking the patient to close each nostril one at a time and identify easily recognized odors. The facial nerve is assessed by asking the patient to raise the eyebrows, close the eyes tightly, purse the lips, draw back the corners of the mouth in an exaggerated smile, and frown. The trochlear nerve is assessed along with oculomotor and abducens nerves, because all three nerves help move the eyes. Test-Taking Tip: When using this program, be sure to note if you guess at an answer. This will permit you to identify areas that need further review. Also it will help you to see how correct your guessing can be.
After a lumbar puncture, the nurse sends the cerebrospinal fluid for investigation. What findings are considered normal for cerebrospinal fluid? Select all that apply.
-pH 7.35 -Glucose 50 mg/dL -Specific gravity 1.007 The normal values of cerebrospinal fluid parameters include specific gravity of 1.007, glucose level of 50 mg/dL, and pH of 7.35. The presence of more than five white blood cells/μL in the cerebrospinal fluid indicates infection. The presence of red blood cells in the cerebrospinal fluid indicates bleeding.
Which neurotransmitter is released by the preganglionic and postganglionic fibers during the parasympathetic response?
Acetylcholine The preganglionic and postganglionic fibers release acetylcholine during a parasympathetic response. The major neurotransmitter released by the postganglionic fibers of the sympathetic nervous system is norepinephrine. Dopamine is an inhibitory neurotransmitter that activates postsynaptic receptors to increase the likelihood that an action potential will be generated. Epinephrine is released by the adrenal glands and is an excitatory neurotransmitter.
The nurse is caring for a patient who has experienced an optic nerve injury after a trauma. Which condition does the nurse recognize is associated with this type of injury?
Anisocoria Anisocoria is a condition caused by an optic nerve injury, in which the pupil of one eye differs in size from the pupil of the other. Dysarthria is associated with the presence of lesions in the cranial nerve. Nystagmus and hemiplegia are muscular disorders. Lesions in the cerebellum, brain stem, or vestibular system cause nystagmus. Hemiplegia is caused due to the presence of lesions in the motor cortex.
The nurse is performing an assessment of the accessory nerve. What should the nurse ask the patient to do?
Ask the patient to shrug the shoulders against resistance. The spinal accessory nerve is tested by asking the patient to shrug the shoulders against resistance and to turn the head to either side against resistance while observing the sternocleidomastoid muscles and the trapezius muscles. Assessing the gag reflex and saying "ah" are used to assess the glossopharyngeal and vagus nerves. Asking the patient to push the tongue to either side against resistance and to stick out the tongue are used to assess the hypoglossal nerve.
How should the nurse most accurately assess the position sense of a patient with a recent traumatic brain injury?
Ask the patient to stand with the feet together and eyes closed and observe for balance maintenance The Romberg test is an assessment of position sense in which the patient stands with the feet together and then closes his or her eyes while attempting to maintain balance. Asking the patient to close his or her eyes and slowly bring the tips of the index fingers together, asking the patient to close his or her eyes and identify the presence of a common object on the forearm, or placing the two points of a calibrated compass on the tips of the fingers and toes and asking the patient to discriminate the points do not directly assess position sense.
A patient's sudden onset of hemiplegia has necessitated a computed tomography (CT) of the head. Which assessment should the nurse complete before this diagnostic study?
Assess the patient for allergies to shellfish, iodine, or dyes Allergies to shellfish, iodine, or dyes contraindicate the use of contrast media in CT. The patient's immunization history is not a central consideration, and the presence of metal in the body does not preclude the use of CT as a diagnostic tool. The need to assess for allergies supersedes the need for tranquilizers or antiseizure medications in the majority of patients
Which cells help in restoring the neurochemical milieu after brain injury?
Astrocyte cells Astrocyte cells help in restoring the neurochemical milieu after brain injury. They also act as phagocytes for neuronal debris and provide support for repair. Schwann cells myelinate the nerve fibers in the periphery. Ependymal cells line the brain ventricles and aid in the secretion of cerebrospinal fluid. Presynaptic cells release an excitatory neurotransmitter.
The nurse reviews a diagnostic test report for a patient with a brain injury which shows neuronal debris and alteration of neurochemical milieu. Which nerve cell can restore the normal condition?
Astrocytes When the brain is injured, astrocytes act as phagocytes for neuronal debris and help restore neurochemical milieu. Microglia plays an important role in inflammation in brain injury. Ependymal cells line the brain ventricles and aid in the secretion of cerebrospinal fluid. Oligodendrocytes are specialized cells that produce the myelin sheath of nerve fibers in the central nervous system.
Which area depicted in the figure is used to obtain cerebrospinal fluid (CSF) during a
B The part labeled B indicates lumbar vertebrae. A larger subarachnoid space in the third and fourth lumbar vertebrae is used to obtain cerebrospinal fluid during lumbar puncture. The part labeled A depicts cervical vertebrae, which provide mobility and stability to the head. The part labeled C indicates the sacrum. The sacrum vertebrae are a fusion of five vertebrae. The part labeled D depicts the coccyx, which serves as an attachment site for muscles, tendons, and ligaments.
A patient has an alteration in sleep-wake transitions causing extreme fatigue. Which part of the central nervous system (CNS) is responsible for this?
Brain stem The brain stem includes the reticular activating system (RAS), which is responsible for regulating arousal and sleep-wake transitions. The cerebrum is responsible for the integration of complex sensory and neural functions, initiation, and coordination of voluntary activity. The cerebellum coordinates voluntary movement and maintains trunk stability and equilibrium. The spinal cord aids in transmission of neural signals between the brain and the rest of the body.
Diagnostic tests of a patient with an intracranial injury reveal increased intracranial pressure with suspected herniation. Which division of the central nervous system has
C Increased intracranial pressure due to increased cerebrospinal fluid pressure can result in herniation of the brain and brain stem. The part labeled C in the figure depicts the pons, which is one of the parts of the brain stem. The part indicated as A in the figure depicts the cerebrum. The part indicated as B in the figure depicts the diencephalon. The part indicated as D in the figure represents the cerebellum. Test-Taking Tip: Emphasize on the etiology of the intracranial injury mentioned in the question and its effects. This helps in selecting the answer correctly.
The nurse is caring for a patient who is experiencing increased intracranial pressure after a head injury. Which glial cell could be the reason for this condition?
Ependymal cells Ependymal cells aid in the secretion of cerebrospinal fluid (CSF). Increased secretion of CSF increases CSF pressure and intracranial pressure, resulting in herniation syndrome. Microglia is involved in phagocytosis. Astrocytes provide structural support to neurons. Schwann cells myelinate the nerve fibers in the periphery.
The nurse is assessing the innervation of the lateral rectus of the eye. Which cranial nerve will the nurse assess?
CN VI The abducens is the sixth cranial nerve, which innervates the lateral rectus of the eye. The trochlear nerve innervates the superior oblique muscle. The accessory nerve innervates the sternocleidomastoid and trapezius muscles. The oculomotor nerve innervates the levator palpebrae muscle. Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question.
A nurse is caring for a patient for whom the health care team suspects cerebral death. Which diagnostic procedure will the nurse prepare the patient for that will confirm this suspicion?
Cerebral angiography Cerebral angiography is a form of angiography that provides images of blood vessels in and around the brain. Lack of cerebral circulation is an important confirmatory test for cerebral death (brain death). A myelogram is an x-ray of the spinal cord and vertebral column performed after an injection of contrast medium into the subarachnoid space. Reflex tests help to assess the integrity of the nerve circuits and are performed to quickly confirm the integrity of the spinal cord or specific nerve root function. Lumbar puncture is done to aspirate cerebrospinal fluid.
Graphesthesia is a test for which integrative sensory function?
Cortical sensory Graphesthesia is a test for cortical sensory function. Reflexes are the contraction of a skeletal muscle that occurs when the tendon is stretched. Vibration sense is tested using a tuning fork that is placed on a bony prominence. The patient's proprioception is tested using the Romberg test.
The nurse is collaborating with the health care provider in the care of a patient with a suspected neurologic injury. The health care provider wants to assess the integrity of the brain stem. What should the nurse prepare to assist the health care provider with?
Cranial nerves Cranial nerves exit the cranium via the brain stem. Assessment of cranial nerves gives a baseline of the brain stem integrity and function. Assessment of reflexes assesses the integrity of the reflex arc, which is the sensory message sent to the brain from the periphery and the motor response that follows. The cerebellum controls balance. Examination of cerebral spinal fluid aids in identifying the increase in diseases and conditions of the brain and spinal column, such as malignancy, infection, and problems with production or movement.
Which part of the spinal cord carries impulses for muscle movement?
Descending tract The descending tract carries impulses that are responsible for muscle movement. The ascending tracts carry specific sensory information to higher levels of the central nervous system. Lower motor neurons and upper motor neurons influence the skeletal muscle movement. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.
While performing an assessment of extraocular movements, the nurse notes the eyes do not move together. How will the nurse document this movement?
Disconjugate With weakness or paralysis of one of the eye muscles, the eyes do not move together. This is described as disconjugate gaze. Nystagmus is fine, rapid jerking movement of the eyes, particularly with lateral gaze. Accommodation is when pupils constrict with near vision. Tracking is when the eyes follow a moving object in a coordinated fashion. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.
The nurse asks the patient to close their eyes and then places the two points of a measuring caliper 1 inch apart on the patient's lower forearm. The nurse asks the patient to identify the sensation. What is the nurse assessing?
Discrimination The nurse is assessing gross two-point discrimination, or the ability of the patient to sense two distinct pressure points. To be most diagnostic, the nurse will move the two points closer together until the patient can no longer distinguish two separate pressure points and the distance is measured. This test aids in diagnosing sensory cortex and peripheral nervous system disorders. Graphesthesia tests the ability to feel writing on the skin. Stereognosis is the ability to perceive the form and nature of an object. Proprioception is when position sense is assessed by moving a body part and asking the patient to identify position.
The health care provider requests a skull x-ray for a patient. Which nursing intervention should the nurse perform to prepare the patient for the procedure?
Explain that the procedure is noninvasive It is important to explain to the patient that a skull x-ray is a noninvasive procedure. This will help to reduce patient anxiety. Nursing preparations such as encouraging fluids, withholding the preceding meal, and emptying bladder do not apply to a skull x-ray. These preparations are applied to procedures such as lumbar puncture, cerebral angiography, and positron emission tomography. Test-Taking Tip: Many times the correct answer is the longest alternative given, but do not count on it. NCLEX item writers (those who write the questions) are also aware of this and attempt to avoid offering you such "helpful hints."
The nurse is assessing a patient who is experiencing altered taste. Which cranial nerve does the nurse assess during the patient's physical examination?
Glossopharyngeal The glossopharyngeal nerve is connected to the medulla and has both sensory and motor functions. The sensory nerve fibers originate from the pharynx and posterior tongue, and the motor nerve fibers are connected to the pharyngeal muscles. Damage to this nerve may result in altered taste. The vagus nerve is also connected to the medulla and has sensory, motor, and parasympathetic fibers. The sensory nerve fibers originate from the viscera of the thorax and abdomen. The motor nerve fibers are connected to the larynx and to the middle and inferior pharyngeal muscles. The parasympathetic nerve fibers are present in the heart, the lungs, and most of the digestive system. The facial nerve is connected to the junction of the pons and medulla and has both motor and sensory nerve fibers. The motor nerve fibers are connected to the facial muscles of expression and to the cheek muscles. The sensory nerve fibers originate from the anterior two thirds of the tongue. The hypoglossal nerve is connected to the medulla; its motor nerves are connected to the muscles of the tongue. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.
A nurse reviews a medical record of a patient who has had a stroke and notes that the medication route has been changed from parenteral to oral. Before administering the oral medications, which cranial nerves should the nurse assess?
Glossopharyngeal and vagus Cranial nerves IX (glossopharyngeal) and X (vagus) control swallowing and the gag reflex. The nurse must assess the gag reflex before administering oral medications or feedings to prevent the risk of aspiration. Cranial nerve VII (facial) controls the motor function of the face and the taste sensation of the anterior two-thirds of the tongue. Cranial nerve V (trigeminal) controls sensation of the forehead, face, nasal cavity, teeth, and eyes, as well as the motor function of the muscles used for mastication. Cranial nerve XII (hypoglossal) controls the motor function of the intrinsic and extrinsic muscles of the tongue.
The nurse is caring for a patient with a diagnosis of frontal lobe dementia. What functional difficulties should the nurse expect in this patient?
Higher cognitive function abnormalities Because the frontal lobe is responsible for higher cognitive function, this patient may have difficulty with memory retention, voluntary eye movements, voluntary motor movement, and expressive speech. The lack of reflexes would occur if the patient had problems with the reflex arcs in the spinal cord. Endocrine problems would be evident if the hypothalamus or pituitary gland were affected. Respiratory, vasomotor, and cardiac dysfunction would occur if there was a problem in the medulla.
Which cranial nerve is responsible for pupillary constriction?
III Cranial nerve III (oculomotor) is responsible for pupillary constriction. Cranial nerve II (optic) is the sensory nerve to the retina of eyes and is responsible for vision. Cranial nerve IV (trochlear) controls motor eye movement. Cranial nerve V (trigeminal) is a sensory motor nerve that has ophthalmic, maxillary, and mandibular branches.
Which cranial nerves that innervate the pharynx are tested together?
IX and X Cranial nerves IX and X (glossopharyngeal and the vagus nerve) are tested together because both innervate the pharynx. Cranial nerve V (the trigeminal nerve) has ophthalmic, maxillary, and mandible branches. Cranial nerve VI (abducens) is a motor nerve for an eye muscle. Cranial nerve VII (the facial cranial nerve) innervates cheek muscles and is responsible for taste in the anterior two-thirds of the tongue. Cranial nerve XII (the hypoglossal cranial nerve) is responsible for the motor muscles of the tongue. Cranial nerve III (oculomotor) innervates the eyes and is responsible for eye movement and smooth muscle eye movement. Cranial nerve VIII (the vestibulocochlear nerve) has vestibular and cochlear nerve branches.
The nurse is caring for a patient with a neurologic disease that affects the pyramidal tract. What assessment finding is the nurse likely to observe?
Impaired muscle movement Among the most important descending tracts are the corticobulbar and corticospinal tracts, collectively termed the pyramidal tract. These tracts carry volitional (voluntary) impulses from the cortex to the cranial and peripheral nerves. Dysfunction of the pyramidal tract is likely to manifest as impaired movement, because of hypertonicity. Diseases affecting the pyramidal tract do not result in changes in LOC, impaired reflexes, or decreased sensation.
A patient with a seizure disorder will undergo electroencephalography. Which nursing intervention should the nurse perform to prepare the patient for the procedure?
Inform the patient that there is no danger of electric shock. In electroencephalography, the electrical activity of the brain is recorded by scalp electrodes to evaluate seizure disorders. It is a noninvasive procedure and without any danger of electric shock. An empty bladder is not required for the test, because the electrodes are placed on the scalp. The patient may wear metal jewelry because their presence does not interfere with the test procedure. Metal jewelry may interfere in tests in which electromagnetic rays are passed through the body, for example, x-rays. The procedure does not involve injecting contrast media; therefore assessment of contraindications to contrast media is not applicable.
During shift hand-off, the off-going registered nurse (RN) reports that the patient had a positive Romberg test on earlier examination. What will be the oncoming nurse's priority intervention?
Inform unlicensed assistive personnel (UAP) that the patient will need assistance with activity. A positive Romberg test indicates that the patient is having difficulty with balance. The nurse will want to inform UAP that the patient is at risk for falls and will need assistance with activity. Elevating all four side rails is considered a restraint in many facilities and should be avoided. There is no indication that seizure precautions are needed. The positive Romberg test alone does not warrant that the patient be placed on strict bedrest, and doing so may lead to complications of immobility. STUDY TIP: Identify your problem areas that need attention. Do not waste time on restudying information you know.
A patient is admitted to the hospital with suspected lesions in Broca's area. What manifestation is the nurse likely to find during assessment?
Irregular speech patterns Broca's area, located at the frontal lobe of the cerebrum, regulates verbal expression. Lesions in Broca's area affect speech production. Visual defects are common if the lesion is in the occipital lobe. Damage to the olfactory bulb may affect the sense of smell. Brainstem injuries may cause difficulty in swallowing.
A patient is suspected of having a lesion involving the subarachnoid space. What problems associated with this lesion does the nurse suspect the patient will have?
Movement of cerebral spinal fluid CSF bathes the brain and spinal cord by traveling along the subarachnoid space. A lesion in this area can interfere with movement of CSF through this space. CSF is produced in the pia mater, which is also the location of the blood brain barrier. The inner layer of the dura mater dips between the two hemispheres to form the tentorium, which aids in communication of impulses between the two hemispheres.
A patient is suspected to have a spinal lesion. What diagnostic test will the nurse prepare the patient for?
Myelogram Myelogram is a radiation technique that helps detect spinal lesions in patients. Transcranial Doppler is an ultrasound examination that helps to evaluate the velocity of blood flow in blood vessels. Cerebral angiography is a radiation technique that examines intracranial and extracranial blood vessels. Cerebral angiography helps detect tumors and vascular lesions in the brain as well. A carotid duplex study is an ultrasound technique that determines the velocity of blood flow in the veins and arteries.
Which is the primary functional unit of the nervous system?
Neuron Neurons are the primary functional unit of the nervous system. The myelin sheath is a white lipid protein substance that acts as an insulator for the conduction of impulses. Axons carry nerve impulses to other neurons or to end organs such as smooth and striated muscles and glands. Dendrites are short processes extending from the cell body that receive impulses or signals from other neurons and conduct them toward the cell body.
Which cells of the nervous system are characterized by excitability, conductivity, and influence?
Neurons Neurons have characteristic features of excitability, conductivity, and influence. Microglia is the specialized macrophage that protects neurons by phagocytosis. Ependymal cells aid in secretion of cerebrospinal fluid. Oligodendrocytes produce the myelin sheath of nerve fibers and provide support to axons in the central nervous system.
What is the location of the visual area in the cerebrum?
Occipital lobe The visual area is located in the occipital lobe of the cerebrum and it registers visual images. The parietal lobe consists of association areas that integrate somatic and sensory output. The anterior temporal lobe has association areas, which integrate past experiences. The posterior temporal lobe consists of association areas that integrate visual and auditory input for language comprehension.
A patient has hemianopsia from a brain lesion. Which cranial nerve does the nurse determine is affected in this patient?
Optic nerve A change in one-half of the visual field resulting from brain lesions is referred to as hemianopsia. Visual fields and acuity assessment will determine the function of the optic nerve. Examination of the olfactory nerve will determine the sense of smell. Examination of the oculomotor nerve will help to assess the movement of the eye. Examination of vestibulocochlear nerve will help assess hearing. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.
Which patient's findings may indicate Alzheimer's disease, based on review of the diagnostic test results of four patients by the nurse?
Patient A Alzheimer's disease is a progressive mental deterioration condition that occurs due to generalized degeneration of the brain. Decreased acetylcholine-secreting neurons cause Alzheimer's disease. Deficiency of γ-aminobutyric acid may cause seizure disorder in Patient B. Increased intracranial pressure (ICP) in Patient C may cause herniation syndrome. A cerebral cortex lesion in Patient D may cause apraxia.
Which patient is susceptible to Parkinson's disease, according to the medical records of four patients that the nurse reviews?
Patient A Parkinson's disease is a progressive disease of the nervous system. Dopamine plays an important role in controlling neuron function. Destruction of dopamine-secreting neurons causes dopamine deficiency, which may result in Parkinson's disease in Patient A. Compression of the nerve root causes cauda equine, as seen in Patient B. Intracranial injury puts Patient C at risk for increased intracranial pressure (ICP). Acute hemorrhage causes the expansion of brain tissue in Patient D.
The nurse is caring for an older adult patient with diminished hearing and visual loss. What type of age-related finding does the nurse determine the patient has developed?
Perceptual confusion The geriatric patient who has reduced hearing and vision are experiencing perceptual confusion. Decreased taste and smell perception are considered sensory changes. Changes in the myelin of the peripheral nervous system result in decreased nerve conduction, which may alter the coordination of neuromuscular activity. Decreased neurotransmitters affect the transmission of impulses and are responsible for a slowed response time. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options .
The nurse suspects that a patient has a damaged accessory nerve. What function is the patient likely to be unable to perform during assessment when requested?
Raise the hand Sternocleidomastoid and trapezius muscles play an important role in hand movement. The accessory nerve controls the function of the sternocleidomastoid and trapezius muscles and an inability to raise the hands indicates damage to the accessory nerve. Hearing impairment indicates damage to the vestibulocochlear nerve. An inability to identify the tastes indicates damage to the facial nerve. An inability to identify smells indicates damage to the olfactory nerve.
The nurse calls out the patient's name in an attempt to arouse them from sleep. What is the nurse assessing the integrity of?
Reticular activating system (RAS) The RAS requires communication among the brainstem, reticular formation, and cerebral cortex. The RAS is responsible for regulating arousal and sleep-wake transitions. The integrity of the reflex arc is assessed by performing reflex assessments, such as patellar and bicep reflexes. The limbic system concerns emotions, aggression, feeding behavior, and sexual response. The autonomic nervous system controls involuntary function of cardiac and smooth muscle and glands. Test-Taking Tip: Do not read too much into the question or worry that it is a "trick." If you have nursing experience, ask yourself how a classmate who is inexperienced would answer this question from only the information provided in the textbooks or given in the lectures.
The nurse is providing care to a patient who is experiencing alterations in mood, sleep, and emotions. Which neurotransmitter may be responsible for the patient's clinical manifestations?
Serotonin Serotonin is an important neurotransmitter in the central nervous system involved in the regulation of mood, sleep, and emotions. The patient's symptoms may be caused by a lack of this neurotransmitter. Acetylcholine acts on cholinergic receptors. A decrease in acetylcholine results in neurologic conditions such as Alzheimer's disease. Norepinephrine is a hormone and neurotransmitter involved in the flight-or-fight response and increasing the heart rate and blood flow to the skeletal muscles. The chief inhibitory neurotransmitter in the central nervous system is γ-aminobutyric acid. It has a role in the regulation of neuronal excitability throughout the nervous system. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.
What portion of the ascending spinal cord tract carries information regarding pain and temperature sensation?
Spinothalamic tracts The spinothalamic tracts are ascending spinal cord tracts that carry pain and temperature sensation to the thalamus. The spinocerebellar tracts carry information about muscle tension and body position to the cerebellum. The dorsal columns carry information about touch, deep pressure, vibration, position sense, and kinesthesia. The pyramidal tracts are descending tracts that carry voluntary impulses from the extrapyramidal system. The extrapyramidal system is concerned with voluntary movement.
The nurse is attempting to elicit the brachioradialis reflex in a patient during a neurologic assessment. What technique will the nurse use that will be most effective?
Strike the radius 3 to 5 cm above the wrist while the patient's arm is relaxed. While eliciting the brachioradialis reflex, the nurse should strike the radius 3 to 5 cm above the wrist while the patient's arm is relaxed. While eliciting the patellar reflex, the nurse should strike the patellar tendon just below the patella while the patient is in a sitting position. While eliciting the biceps reflex, the nurse should strike the thumb with a hammer by placing the thumb over the biceps tendon in the antecubital space. While eliciting the Achilles tendon reflex, the nurse strikes the Achilles tendon while the patient's leg is flexed at the knee and the foot is gently dorsiflexed.
A patient informs the nurse about having chest pain after being frightened when a fire broke out on the stove. Which division of the nervous system does the nurse recognize activates the "fight or flight" response?
Sympathetic nervous system The sympathetic nervous system is a part of the autonomic nervous system. It activates the mechanism of "fight or flight" in response to stress. The central nervous system integrates the received information as well as coordinates and influences the activities of all parts of the body. The peripheral nervous system sends information from the different body parts to the brain. The parasympathetic nervous system, also part of the autonomic nervous system, is responsible for stimulation of rest and digestion activities.
A patient with a lesion in the central nervous system has developed spasticity with hyperreflexia, weakness, paralysis in the lower extremities, and disuse atrophy. Where does the nurse suspect this lesion may be located according to the clinical manifestations?
Upper motor neurons Upper motor neurons influence skeletal muscle movement. Upper motor neuron lesions generally cause weakness or paralysis, disuse atrophy, hyperreflexia, and spasticity. Reflex arcs play an important role in maintaining muscle tone. The motor output exits the spinal cord by way of the ventral roots of the spinal nerves. Descending tract lower motor neuron lesions generally cause weakness or paralysis, denervation atrophy, hyporeflexia or areflexia, and decreased muscle tone (flaccidity). Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.
Which cranial nerve is responsible for the sense of hearing?
VIII (vestibulocochlear) Cranial nerve VIII (vestibulocochlear) is an auditory sensory nerve and is involved in equilibrium. Cranial nerve I (olfactory) is responsible for the sense of smell. Cranial nerve V (trigeminal) is responsible for chewing and many sensory nerves from the forehead to the lower jaw. Cranial nerve VII (facial) controls some of the motor functions of the face and taste.
The assessment of temperature sensation occurs in which situation?
When the pain reflex is absent In the absence of pain, temperature sensation is assessed. If the pain sensation is intact, the assessment of temperature sensation may be omitted, because the same ascending pathways carry both sensations. The pronator drift test is a motor systems test. Extinction is an assessment that occurs by simultaneously touching both sides of the body symmetrically to assess for the perception of symmetrical sensation. A sensory system assessment does include a pain assessment. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers.
The nurse requests a patient to shrug the shoulders and turn the head side to side against resistance. Which cranial nerve is the nurse assessing?
XI Asking a patient to shrug shoulders and turn the head side to side against resistance is a method to test cranial nerve XI, the accessory nerve. Cranial nerves VI, VII, and XI have different methodologies of assessment.
