Chapter 56

○ The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain?

Nail bed pressure

○ Several patients have been hospitalized for diagnosis of neurologic problems. Which patient will the nurse assess first?

Patient with a brain tumor who has just arrived on the unit after a cerebral angiogram

○ Which nursing diagnosis is expected to be appropriate for a patient who has a positive Romberg test?

Risk for falls

○ Which priority instruction or precaution does the nurse teach a client who is scheduled for a positron emission tomography scan of the brain?

■ "Avoid caffeine-containing substances for 12 hours before the test."

○ The nurse is preparing a client for magnetic resonance angiography. Which question is a priority at this time?

■ "Do you have allergies to iodine or shellfish?"

○ A female client with deteriorating neurologic function states, "I am worried I will not be able to care for my young children." How does the nurse respond?

■ "Give me more information about what worries you, so we can see if we can do something to make adjustments."

○ Before electroencephalography, a client asks, "Why will I be asked to take deep breaths during the procedure?" How does the nurse respond?

■ "Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity."

○ The nurse is teaching a client before magnetic resonance imaging (MRI). Which statement indicates that the client understands the content of the education?

■ "I can return to my usual activities immediately after the MRI."

○ The nurse is assessing a client's remote memory. Which statement by the client confirms that remote memory is intact?

■ "I was born on April 3, 1967, in Johnstown Community Hospital."

○ The nurse is discharging an 80-year-old client with diminished touch sensation. Which instruction does the nurse provide to promote client safety?

■ "Look at the placement of your feet when walking."

○ A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate?

■ "The obstructing plaque is surgically removed from an artery in the neck."

○ Immediately after a lumbar puncture, the client begins to vomit and an IV is started with normal saline (0.9% NS). The provider orders a 200-mL bolus over 15 minutes. Using an infusion pump that delivers mL/hr, the rate at which the nurse sets the pump is _____ mL.

■ 800

○ In which patient would it be the most important for the nurse to assess the glossopharyngeal and vagus nerves?

■ A 50-year-old woman with lethargy from a drug overdose

○ A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has:

■ An intact brainstem

○ The nurse is completing a health assessment for an obese 62-year-old man who wants to begin a diet and exercise program. Which assessment should the nurse perform to determine the cognitive function of the patient during the physical examination?

■ Ask the patient a question such as, "Who were the last three presidents?"

○ When assessing the accessory nerve, what should the nurse do?

■ Ask the patient to shrug the shoulders against resistance

○ The nurse cares for a 34-year-old woman after a lumbar puncture. Which action by the nurse is most appropriate?

■ Assess for drainage or bleeding from the puncture site.

○ After performing a physical assessment on a 75-year-old client, the nurse notes that the client has a hypoactive response to a test of deep tendon reflexes. Which intervention does the nurse include in this client's plan of care?

■ Assist the client with ambulation.

○ The nurse is assessing the deep tendon reflexes of a client with long-standing diabetes mellitus. Which clinical manifestation does the nurse expect to see?

■ Bilateral hypoactive reflexes

○ Which nursing action will be included in the care for a patient who has had cerebral angiography?

■ Check pulse and blood pressure frequently.

○ The nurse is caring for a client post-cerebral angiography via the client's right femoral artery. Which intervention does the nurse implement?

■ Check the right lower extremity pulses.

○ A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis?

■ Cloudy CSF, elevated protein, and decreased glucose

○ A client admitted the previous day for a suspected neurologic disorder becomes increasingly lethargic. Which is the best nursing action?

■ Complete a full neurologic assessment and notify the neurologist.

○ A client is scheduled for a single-photon emission computed tomography test. Which condition in the client's history causes the nurse to contact the provider before the test takes place?

■ Currently breast feeding

○ During a neurologic assessment of a client, the nurse notes that the client's arms, wrists, and fingers have become flexed, and internal rotation and plantar flexion of the legs are evident. How does the nurse document these findings?

■ Decorticate posturing

○ The nurse is assessing a client with a temporal lobe injury. Which clinical manifestations correlate with this injury? (Select all that apply.)

■ Difficulty with sound interpretation ■ Speech difficulties ■ Personality changes

○ The nurse is planning care for an 83-year-old client with age-related changes to his sensory perception. Which nursing action does the nurse implement to ensure the client's safety?

■ Ensure that the path to the bathroom is free from equipment.

○ A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to:

■ Escape the source of pain

○ The nurse is evaluating a client's physical assessment with the medical history and treatment plan. The nurse notes that the client's right pupil appears dilated, with a sluggish pupillary response to light. Which disorder and related treatment does this physical finding correlate with?

■ Glaucoma and intraocular pressure-reducing eye drops

○ In a client with an injury to the medulla, the nurse monitors for which clinical manifestations secondary to damage of cranial nerves that emerge from the medulla? (Select all that apply.)

■ Impaired swallowing ■ Inability to shrug shoulders ■ Loss of gag reflex

○ The nurse is caring for a client who had a computed tomography (CT) scan of the head with contrast medium. Which priority intervention does the nurse implement?

■ Increase fluid intake after the procedure

○ The nurse is administering a medication to a client that stimulates the sympathetic division of the autonomic nervous system. Which clinical manifestations does the nurse monitor for? (Select all that apply.)

■ Increased heart rate ■ Increased force of contraction

○ The nurse is obtaining the health history of a client scheduled for magnetic resonance imaging (MRI). Which condition requires the nurse to cancel the MRI?

■ Internal insulin pump

○ Which neurologic test or procedure requires the nurse to determine whether an informed consent has been obtained from the client before the test or procedure?

■ Lumbar puncture for cerebrospinal fluid (CSF) sampling

○ Which assessments will the nurse make to monitor a patient's cerebellar function (select all that apply)?

■ Observe arm swing with gait. ■ Perform the finger-to-nose test

○ A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first?

■ Obtain oxygen saturation.

While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional?

■ Parietal

○ Which cerebrospinal fluid analysis result will be most important for the nurse to communicate to the health care provider?

■ Protein 65 mg/dL (0.65 g/L)

○ A patient with heart failure and type 1 diabetes mellitus is scheduled for a positron emission tomography (PET) of the brain. Which medication prescribed by the health care provider should the nurse expect to administer before the diagnostic study?

■ Regular insulin 6 units (SQ)

○ A client is scheduled for magnetic resonance imaging (MRI). Which action does the nurse implement before the test?

■ Replace the client's gown with metal snaps with one that has cloth ties.

○ The nurse is assessing a client scheduled for a lumbar puncture. Which clinical manifestation assessed by the nurse complicates the lumbar puncture procedure?

■ Restlessness and agitation

○ The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure?

■ Side-lying, with legs pulled up and head bent down onto the chest

○ Problems with memory and learning would relate to which of the following lobes?

■ Temporal

○ The nurse is preparing the patient for an electromyography (EMG). What should the nurse include in teaching the patient before the test?

■ The pain that occurs is from the insertion of the needles

○ A 39-year-old patient with a suspected herniated intervertebral disc is scheduled for a myelogram. Which information is most important for the nurse to communicate to the health care provider before the procedure?

■ The patient has an allergy to shellfish.

○ While assessing pain discrimination, a client correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. How does the nurse then proceed with the examination?

■ Touch the pin on the same area of the left hand.

○ Which equipment will the nurse obtain to assess vibration sense in a diabetic patient who has peripheral nerve dysfunction?

■ Tuning fork

○ Which information about a 76-year-old patient is most important for the admitting nurse to report to the patient's health care provider?

■ Unintended weight loss of 20 pounds

○ Which action will the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X)?

■ Withhold oral fluid or foods.

○ A patient is having a transsphenoidal hypophysectomy. The nurse should provide preoperative patient teaching about what potential deficit as a result of the surgery?

■ altered sense of smell

○ When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as

■ decorticate posturing.

○ During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurse's directions to move his hands and feet. The nurse will suspect

■ frontal lobe damage.

○ After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about

■ oral low-dose aspirin therapy.

○ The nurse is caring for a group of well older people at a community day center. Which neurologic finding associated with aging would the nurse expect to find in older adults?

■ orthostatic hypertension

○ A 45-year-old patient has a dysfunction of the cerebellum. The nurse will plan interventions to

■ prevent falls.

○ The priority nursing assessment for a 72-year-old patient being admitted with a brainstem infarction is

■ respiratory rate and rhythm.

○ Which normal nervous system changes of aging put the geriatric person at higher risk of falls (select all that apply)?

■ sensory deficit ■ motor function deficit ■ central nervous system changes

○ To assess the functioning of the trigeminal and facial nerves (CNs V and VII), the nurse should

■ shine a light into the patient's pupil.

○ When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis

■ to call the health care provider if stools are bloody or tarry

○ The nurse performing a focused assessment of left posterior temporal lobe functions will assess the patient for

■ understanding written and oral language.

○ During a neurologic examination, a client demonstrates a positive Romberg's sign with eyes closed, but not with eyes open. Which condition does the nurse associate with this finding?

Difficulty with proprioception

○ A patient who has a neurologic disease that affects the pyramidal tract is likely to manifest what sign?

Impaired muscle movement