Chapter 65: Assessment Of Neurologic Function

11. The patient in the ED has just had a diagnostic lumbar puncture. To reduce the incidence of a post-lumbar puncture headache, what is the nurses most appropriate action? A) Position the patient prone. B) Position the patient supine with the head of bed flat. C) Position the patient left side-lying. D) Administer acetaminophen as ordered.

A

4. The nurse has admitted a new patient to the unit. One of the patients admitting orders is for an adrenergic medication. The nurse knows that this medication will have what effect on the circulatory system? A) Thin, watery saliva B) Increased heart rate C) Decreased BP D) Constricted bronchioles

B

24. Assessment is crucial to the care of patients with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply. A) The ability to select mediations for the neurologic dysfunction B) Understanding of the tests used to diagnose neurologic disorders C) Knowledge of nursing interventions related to assessment and diagnostic testing D) Knowledge of the anatomy of the nervous system E) The ability to interpret the results of diagnostic tests

B, C, D

19. The nurse educator is reviewing the assessment of cranial nerves. What should the educator identify as the specific instances when cranial nerves should be assessed? Select all that apply. A) When a neurogenic bladder develops B) When level of consciousness is decreased C) With brain stem pathology D) In the presence of peripheral nervous system disease E) When a spinal reflex is interrupted

B,C, D

7. What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brains surface? A) Dura mater B) Arachnoid C) Fascia D) Pia mater

D The term meninges describes the fibrous connective tissue that covers the brain and spinal cord. The meninges have three layers, the dura mater, arachnoid, and pia mater. The pia mater is the innermost membrane that hugs the brain closely and extends into every fold of the brains surface. The dura mater, the outermost layer, covers the brain and spinal cord. The arachnoid, the middle membrane, is responsible for the production of cerebrospinal fluid.

16. A patient is being given a medication that stimulates her parasympathetic system. Following administration of this medication, the nurse should anticipate what effect? A) Constricted pupils B) Dilated bronchioles C) Decreased peristaltic movement D) Relaxed muscular walls of the urinary bladder

a

17. A patient with lower back pain is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should prioritize what action? A) Positioning the patient with the head of the bed elevated 45 degrees B) Administering IV morphine sulfate to prevent headache C) Limiting fluids for the next 12 hours D) Helping the patient perform deep breathing and coughing exercises

a

22. A patient is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this patient, the nurse has the patient stick out her tongue and move it back and forth. What is the nurse assessing? A) Function of the hypoglossal nerve B) Function of the vagus nerve C) Function of the spinal nerve D) Function of the trochlear nerve

a

33. A patient is scheduled for a myelogram and the nurse explains to the patient that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests? A) Lumbar puncture B) MRI C) Cerebral angiography D) EEG

a

29. A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution? A) Hot or cold packs B) Analgesics C) Anti-inflammatory medications D) Whirlpool baths

a Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used. The older patient may be burned or suffer frostbite before being aware of any discomfort. Any medication is used with caution in the elderly, but not because of the decreased sense of heat or cold. Whirlpool baths are generally not a routine treatment ordered for the elderly.

14. A patient exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most plausible cause of this patients health problem? A) Cerebellar dysfunction B) A lesion in the pons C) Dysfunction of the medulla D) A hemorrhage in the midbrain

a The cerebellum controls fine movement, balance, position sense, and integration of sensory input. Portions of the pons control the heart, respiration, and blood pressure. Cranial nerves IX through XII connect to the brain in the medulla. Cranial nerves III and IV originate in the midbrain.

2. A patient scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the patient for the MRI should prioritize which of the following actions? A) Withholding stimulants 24 to 48 hours prior to exam B) Removing all metal-containing objects C) Instructing the patient to void prior to the MRI D) Initiating an IV line for administration of contrast

b

21. The nurse is planning the care of a patient with Parkinsons disease. The nurse should be aware that treatment will focus on what pathophysiological phenomenon? A) Premature degradation of acetylcholine B) Decreased availability of dopamine C) Insufficient synthesis of epinephrine D) Delayed reuptake of serotonin

b

26. The nurse is caring for a patient who exhibits abnormal results of the Weber test and Rinne test. The nurse should suspect dysfunction involving what cranial nerve? A) Trigeminal B) Acoustic C) Hypoglossal D) Trochlear

b

30. A trauma patient in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death? A) Magnetic resonance imaging (MRI) B) Electroencephalography (EEG) C) Electromyelography (EMG) D) Computed tomography (CT)

b

34. The physician has ordered a somatosensory evoked responses (SERs) test for a patient for whom the nurse is caring. The nurse is justified in suspecting that this patient may have a history of what type of neurologic disorder? A) Hypothalamic disorder B) Demyelinating disease C) Brainstem deficit D) Diabetic neuropathy

b

37. The nurse is performing a neurologic assessment of a patient whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the patients level of consciousness (LOC)? A) Assess the patients vital signs and correlate these with the patients baselines. B) Assess the patients eye opening and response to stimuli. C) Document that the patient currently lacks a level of consciousness. D) Facilitate diagnostic testing in an effort to obtain objective data.

b

38. In the course of a focused neurologic assessment, the nurse is palpating the patients major muscle groups at rest and during passive movement. Data gleaned from this assessment will allow the nurse to describe which of the following aspects of neurologic function? A) Muscle dexterity B) Muscle tone C) Motor symmetry D) Deep tendon reflexes

b

A patient is brought to the ER following a motor vehicle accident in which he sustained head trauma. Preliminary assessment reveals a vision deficit in the patients left eye. The nurse should associate this abnormal finding with trauma to which of the following cerebral lobes? A) Temporal B) Occipital C) Parietal D) Frontal

b

6. The nurse is doing an initial assessment on a patient newly admitted to the unit with a diagnosis of cerebrovascular accident (CVA). The patient has difficulty copying a figure that the nurse has drawn and is diagnosed with visual-receptive aphasia. What brain region is primarily involved in this deficit? A) Temporal lobe B) Parietal-occipital area C) Inferior posterior frontal areas D) Posterior frontal area

b Difficulty copying a figure that the nurse has drawn would be considered visual-receptive aphasia, which involves the parietal-occipital area. Expressive aphasia, the inability to express oneself, is often associated with damage to the frontal area. Receptive aphasia, the inability to understand what someone else is saying, is often associated with damage to the temporal lobe area.

3. A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, agerelated changes. Of what phenomenon should the nurse be aware? A) Hyperactive deep tendon reflexes B) Reduction in cerebral blood flow C) Increased cerebral metabolism D) Hypersensitivity to painful stimuli

b Reduction in cerebral blood flow (CBF) is a change that occurs in the normal aging process. Deep tendon reflexes can be decreased or, in some cases, absent. Cerebral metabolism decreases as the patient advances in age. Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used.

20. A patient in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is which of the following? A) Cerebellum B) Thalamus C) Hypothalamus D) Midbrain

c

23. A trauma patient was admitted to the ICU with a brain injury. The patient had a change in level of consciousness, increased vital signs, and became diaphoretic and agitated. The nurse should recognize which of the following syndromes as the most plausible cause of these symptoms? A) Adrenal crisis B) Hypothalamic collapse C) Sympathetic storm D) Cranial nerve deficit Ans: C Feedback: Sympathetic storm is a syndrome associated with changes in level of consciousness, altered vital signs, diaphoresis, and agitation that may result from hypothalamic stimulation of the sympathetic nervous system following traumatic brain injury. Alterations in cranial nerve or adrenal function would not have this result

c

25. When caring for a patient with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would the nurse use to elicit a response from cranial nerve VII? A) Palpate trapezius muscle while patient shrugs should against resistance. B) Administer the whisper or watch-tick test. C) Observe for facial movement symmetry, such as a smile. D) Note any hoarseness in the patients voice.

c

27. The nurse caring for an 80 year-old patient knows that she has a pre-existing history of dulled tactile sensation. The nurse should first consider what possible cause for this patients diminished tactile sensation? A) Damage to cranial nerve VIII B) Adverse medication effects C) Age-related neurologic changes D) An undiagnosed cerebrovascular accident in early adulthood

c

31. A patient is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the patient in preparation for this test? A) No metal objects can enter the procedure room. B) You need to fast for 8 hours prior to the test. C) You will need to lie still throughout the procedure. D) There will be a lot of noise during the test.

c

35. A patient had a lumbar puncture performed at the outpatient clinic and the nurse has phoned the patient and family that evening. What does this phone call enable the nurse to determine? A) What are the patients and familys expectations of the test B) Whether the patients family had any questions about why the test was necessary C) Whether the patient has had any complications of the test D) Whether the patient understood accurately why the test was done

c

5. A nurse is assessing reflexes in a patient with hyperactive reflexes. When the patients foot is abruptly dorsiflexed, it continues to beat two to three times before settling into a resting position. How would the nurse document this finding? A) Rigidity B) Flaccidity C) Clonus D) Ataxia

c

8. The nurse is caring for a patient with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the patients neurologic assessment? A) Decreased muscle tone B) Flaccid paralysis C) Loss of voluntary control of movement D) Slow reflexes

c

How many cranial nerves does the nurse have to assess? A.10 B.11 C.12 D.13

c

40. During the performance of the Romberg test, the nurse observes that the patient sways slightly. What is the nurses most appropriate action? A) Facilitate a referral to a neurologist. B) Reposition the patient supine to ensure safety. C) Document successful completion of the assessment. D) Follow up by having the patient perform the Rinne test.

c Slight swaying during the Romberg test is normal, but a loss of balance is abnormal and is considered a positive Romberg test. Slight swaying is not a significant threat to the patients safety. The Rinne test assesses hearing, not balance

18. A patient is having a fight or flight response after receiving bad news about his prognosis. What affect will this have on the patients sympathetic nervous system? A) Constriction of blood vessels in the heart muscle B) Constriction of bronchioles C) Increase in the secretion of sweat D) Constriction of pupils

c sympathetic nervous system stimulation results in dilated blood vessels in the heart and skeletal muscle, dilated bronchioles, increased secretion of sweat, and dilated pupils.

10. An elderly patient is being discharged home. The patient lives alone and has atrophy of his olfactory organs. The nurse tells the patients family that it is essential that the patient have what installed in the home? A) Grab bars B) Nonslip mats C) Baseboard heaters D) A smoke detector

d

13. A nurse is caring for a patient diagnosed with Mnires disease. While completing a neurologic examination on the patient, the nurse assesses cranial nerve VIII. The nurse would be correct in identifying the function of this nerve as what? A) Movement of the tongue B) Visual acuity C) Sense of smell D) Hearing and equilibrium

d

15. The nursing students are learning how to assess function of cranial nerve VIII. To assess the function of cranial nerve VIII the students would be correct in completing which of the following assessment techniques? A) Have the patient identify familiar odors with the eyes closed. B) Assess papillary reflex. C) Utilize the Snellen chart. D) Test for air and bone conduction (Rinne test).

d

28. A 72-year-old man has been brought to his primary care provider by his daughter, who claims that he has been experiencing uncharacteristic lapses in memory. What principle should underlie the nurses assessment and management of this patient? A) Loss of short-term memory is normal in older adults, but loss of long-term memory is pathologic. B) Lapses in memory in older adults are considered benign unless they have negative consequences. C) Gradual increases in confusion accompany the aging process. D) Thorough assessment is necessary because changes in cognition are always considered to be pathologic.

d

32. A patient for whom the nurse is caring has positron emission tomography (PET) scheduled. In preparation, what should the nurse explain to the patient? A) The test will temporarily limit blood flow through the brain. B) An allergy to iodine precludes getting the radio-opaque dye. C) The patient will need to endure loud noises during the test. D) The test may result in dizziness or lightheadedness.

d

39. The neurologic nurse is testing the function of a patients cerebellum and basal ganglia. What action will most accurately test these structures? A) Have the patient identify the location of a cotton swab on his or her skin with the eyes closed. B) Elicit the patients response to a hypothetical problem. C) Ask the patient to close his or her eyes and discern between hot and cold stimuli. D) Guide the patient through the performance of rapid, alternating movements.

d

9. The nurse is admitting a patient to the unit who is diagnosed with a lower motor neuron lesion. What entry in the patients electronic record is most consistent with this diagnosis? A) Patient exhibits increased muscle tone. B) Patient demonstrates normal muscle structure with no evidence of atrophy. C) Patient demonstrates hyperactive deep tendon reflexes. D) Patient demonstrates an absence of deep tendon reflexes.

d

12. The nurse is conducting a focused neurologic assessment. When assessing the patients cranial nerve function, the nurse would include which of the following assessments? A) Assessment of hand grip B) Assessment of orientation to person, time, and place C) Assessment of arm drift D) Assessment of gag reflex

d The gag reflex is governed by the glossopharyngeal nerve, one of the cranial nerves. Hand grip and arm drifting are part of motor function assessment. Orientation is an assessment parameter related to a mental status examination.

36. A patient is currently being stimulated by the parasympathetic nervous system. What effect will this nervous stimulation have on the patients bladder? A) The parasympathetic nervous system causes urinary retention. B) The parasympathetic nervous system causes bladder spasms. C) The parasympathetic nervous system causes urge incontinence. D) The parasympathetic nervous system makes the bladder contract.

d The parasympathetic division of the nervous system causes contraction (stimulation) of the urinary bladder muscles and a decrease (inhibition) in heart rate, whereas the sympathetic division produces relaxation (inhibition) of the urinary bladder and an increase (stimulation) in the rate and force of the heartbeat.

Is the following statement true or false? The autonomic nervous system regulates involuntary body functions

true