Chapter 65: Assessment of Neurologic Function
There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected with decreased visual fields. Cranial nerve I Cranial nerve II Cranial nerve III Cranial nerve IV
Cranial nerve II Explanation: The three sensory cranial nerves are I, II and VIII. Cranial nerve II (optic) is affected with decreased visual fields and acuity. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Table 65-2, p. 1952.
What safety actions does the nurse need to take for a client receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)? Securely fasten the client's portable oxygen tank to the bottom of the MRI table after the client has been positioned on the top of the MRI table Check the client's oxygen saturation level using a pulse oximeter after the client has been placed on the MRI table Note that no special safety actions need to be taken Ensure that no client care equipment containing metal enters the room where the MRI is located.
Ensure that no client care equipment containing metal enters the room where the MRI is located. Explanation: For client safety the nurse must make sure no client care equipment that contains metal or metal parts (e.g., portable oxygen tanks) enters the room where the MRI is located. The magnetic field generated by the unit is so strong that any metal-containing items will be strongly attracted and can literally be pulled away with such great force that they can fly like projectiles toward the magnet. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, p. 1966.
The trochlear nerve controls which function? Movement of the tongue Hearing and equilibrium Visual acuity Eye muscle movement
Eye muscle movement Explanation: The trochlear nerve coordinates the muscles that move the eye. The acoustic nerve functions in hearing and equilibrium. The optic nerve functions in visual acuity and visual fields. The hypoglossal nerve functions in the movement of the tongue. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Table 65-2, p. 1952.
The sympathetic and parasympathetic nervous systems have a direct effect on the circulatory system. Stimulation of the parasympathetic nervous system (PNS) causes which of the following? Blood vessels in the heart muscle to dilate Heartbeat to decrease Blood pressure to increase Blood vessels in the skeletal muscles to dilate
Heartbeat to decrease Explanation: The parasympathetic nervous system has a constricting effect on the blood vessels in the heart and skeletal muscles; the heartbeat and blood pressure will decrease. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Parasympathetic Nervous System, p. 1954.
A client presents to the emergency department status post-seizure. The physician wants to know what the pressure is in the client's head. What test might be ordered on this client? Lumbar puncture Echoencephalography Nerve conduction studies EMG
Lumbar puncture Explanation: Changes in CSF occur in many neurologic disorders. A lumbar puncture (spinal tap) is performed to obtain samples of CSF from the subarachnoid space for laboratory examination and to measure CSF pressure. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Cerebrospinal Fluid, p. 1950.
The nurse is caring for a client who is to have a lumbar puncture. What are the lowest vertebrae that contain the spinal cord? Coccyx Second lumbar vertebrae Eleventh thoracic vertebrae Fifth lumbar vertebrae
Second lumbar vertebrae Explanation: The spinal cord ends between the first and second lumbar vertebrae. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Lumbar Puncture and Examination of Cerebrospinal Fluid, p. 1969.
When learning about the nervous system, students learn that which nervous system regulates the expenditure of energy? Parasympathetic Central Peripheral Sympathetic
Sympathetic Explanation: Sympathetic Nervous System: This division of the autonomic nervous system regulates the expenditure of energy. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Sympathetic Nervous System, p. 1953.
The spinal cord is composed of 31 pairs of spinal nerves. How many pairs of thoracic nerves are contained within the spinal column? Twelve Five One Eight
Twelve Explanation: There are twelve pairs of thoracic nerves, five lumbar and sacral nerves, eight cervical, and one coccygeal. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Vertebral Column, p. 1951.
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? bronchodilator antihistamine cardio tonic antibiotic
antihistamine Explanation: Clients with an allergy history are administered a pretest dose of an antihistamine. Antihistamines block histamine receptors and reduce the manifestations of an allergic reaction. The other options are not administered in the pretest period. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 65: Assessment of Neurological Function, p. 1966.
Lower motor neuron lesions cause increased muscle tone. flaccid muscles. no muscle atrophy. hyperactive and abnormal reflexes.
flaccid muscles. Explanation: Lower motor neuron lesions cause flaccidity, muscle atrophy, decreased muscle tone, and loss of voluntary control. Upper motor neuron lesions cause increased muscle tone. Upper motor neuron lesions cause no muscle atrophy. Upper motor neuron lesions cause hyperactive and abnormal reflexes. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, p. 1956.
The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart? CN I CN II CN III CN IV
CN II Explanation: The nurse assesses vision and thus the optic nerve (cranial nerve II) by use of a Snellen eye chart. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Table 65-2, p. 1952.
What part of the brain controls and coordinates muscle movement? Cerebellum Cerebrum Midbrain Brain stem
Cerebellum Explanation: The cerebellum, which is located behind and below the cerebrum, controls and coordinates muscle movement. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Cerebellum, p. 1949.
A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position? Head of the bed elevated 45 degrees Prone Supine with feet raised Supine with the head lower than the trunk
Head of the bed elevated 45 degrees Explanation: After a myelogram, positioning depends on the dye injected. When a water-soluble dye such as metrizamide is injected, the head of the bed is elevated to a 45-degree angle to slow the upward dispersion of the dye. The prone and supine positions are contraindicated when a water-soluble contrast dye is used. The client should be positioned supine with the head lower than the trunk after an air-contrast study. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Nursing Interventions, p. 1968.
Which term describes the fibrous connective tissues that cover the brain and spinal cord? Meninges Dura mater Arachnoid mater Pia mater
Meninges Explanation: The meninges have three layers: the dura mater, arachnoid mater, and pia mater. The dura mater is the outermost layer of the protective covering of the brain and spinal cord. The arachnoid is the middle membrane, and the pia mater is the innermost membrane of this protective covering. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, p. 1949.
Which cranial nerve is responsible for muscles that move the eye and lids? Oculomotor Trigeminal Vestibulocochlear Facial
Oculomotor Explanation: The oculomotor (III) cranial nerve is also responsible for pupillary constriction and lens accommodation. The trigeminal (V) cranial nerve is responsible for facial sensation, corneal reflex, and mastication. The vestibulocochlear (VIII) cranial nerve is responsible for hearing and equilibrium. The facial (VII) nerve is responsible for salivation, tearing, taste, and sensation in the ear. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Table 65-2, p. 1952.
The nurse is performing a neurologic assessment and requests that the patient stand with eyes open and then closed for 20 seconds to assess balance. What type of test is the nurse performing? Weber test Rinne test Romberg test Watch-tick test
Romberg test Explanation: The Romberg test is a neurologic assessment of the patient's balance in which the patient is instructed to stand with eyes open and then closed for 20 seconds. The Weber (including the watch-tick) and Rinne tests assess hearing. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Balance and Coordination, p. 1961.
A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain? III IV V VI
V Explanation: The trigeminal nerve (cranial nerve V) innervates the forehead, cheeks, and jaw, so pain in the face elicited when brushing the teeth would most likely involve this nerve. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Table 65-2, p. 1952.
The nurse is performing a neurologic assessment on a client diagnosed with a stroke and cannot elicit a gag reflex. This deficit is related to which of the following cranial nerves? VIII X III VII
X Explanation: CN X is the vagus nerve and has to do with the gag reflex, laryngeal hoarseness, swallowing ability, and the symmetrical rise of the uvula and soft palate. CN VII is the facial nerve and has to do with symmetry of facial movements and the ability to discriminate between the tastes of sugar and salt. The inability to close one eyelid indicates impairment of this nerve. CN VIII is the acoustic nerve. It has to do with hearing, air and bone conduction, and balance. CN III is the oculomotor nerve and has to do with pupillary response, conjugate movements, and nystagmus. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Table 65-2, p. 1952.
A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates: dysfunction in the cerebrum. risk for increased intracranial pressure. dysfunction in the brain stem. dysfunction in the spinal column.
dysfunction in the brain stem. Explanation: Decerebrate posturing indicates damage of the upper brain stem. Decorticate posturing indicates cerebral dysfunction. Increased intracranial pressure is a cause of decortication and decerebration. Alterations in sensation or paralysis indicate dysfunction in the spinal column.
A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term? Ataxic Dystrophic Helicopod Steppage
Helicopod Explanation: A helicopod gait is an abnormal gait in which the client's feet make a half circle with each step. An ataxic gait is staggering and unsteady. In a dystrophic gait, the client waddles with the legs far apart. In a steppage gait, the feet and toes rise high off the floor and the heel comes down heavily with each step.
The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply. Unequal pupils Pupil reaction quick Pinpoint pupils Absence of pupillary response Pupil reacts to light
Unequal pupils Pinpoint pupils Absence of pupillary response Explanation: Normal assessment findings includes that the pupils are equal and reactive to light. Pupils that are unequal, pinpoint in nature, or fail to respond indicate a neurologic impairment. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Other Neurologic Signs, p. 2042.
To evaluate a client's cerebellar function, a nurse should ask: "Do you have any problems with balance?" "Do you have any difficulty speaking?" "Do you have any trouble swallowing food or fluids?" "Have you noticed any changes in your muscle strength?"
"Do you have any problems with balance?" Explanation: To evaluate cerebellar function, the nurse should ask the client about problems with balance and coordination. The nurse asks about difficulty speaking or swallowing to assess the functions of cranial nerves IX, X, and XII. Questions about muscle strength help her evaluate the client's motor system. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Cerebellum, p. 1949.
Cranial nerve IX is also known as which of the following? Glossopharyngeal Vagus Spinal accessory Hypoglossal
Glossopharyngeal Explanation: Cranial nerve IX is the glossopharyngeal nerve. The vagus nerve is cranial nerve X. Cranial nerve XII is the hypoglossal nerve. The spinal accessory is the cranial nerve XI. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Table 65-2, p. 1952.
A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in thought content. motor ability. intellectual function. emotional status.
thought content. Explanation: Hallucinations are disturbances of thought content. They are not disturbances in motor ability, intellectual function, or emotional status. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, p. 1959.
The pre-nursing class is learning about the nervous system in their anatomy class. What part of the nervous system would the students learn is responsible for digesting food and eliminating body waste? Central Sympathetic Peripheral Parasympathetic
Parasympathetic Explanation: The parasympathetic division of the autonomic nervous system works to conserve body energy and is partly responsible for slowing heart rate, digesting food, and eliminating body wastes. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Parasympathetic Nervous System, p. 1954.
A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for: hypoxia. fever. visual disturbance. gait alteration.
hypoxia. Explanation: Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing, and coughing. Therefore, the nurse should monitor the client closely for hypoxia. Temperature control, vision, and gait aren't lower brain stem functions. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Brain Stem, p. 1949.
Which term refers to the inability to coordinate muscle movements, resulting in difficulty walking? Agnosia Ataxia Spasticity Rigidity
Ataxia Explanation: Ataxia is the inability to coordinate voluntary muscle action; tremors (rhythmic, involuntary movements) noted at rest or during movement suggest a problem in the anatomic areas responsible for balance and coordination. Agnosia is the loss of ability to recognize objects through a particular sensory system. Spasticity is the sustained increase in tension of a muscle when it is passively lengthened or stretched. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, p. 1961.
A nurse is preparing a client for a lumbar puncture and informs the client that the needle will be inserted into the subarachnoid space between L3 and L4 or L4 and L5. The client reports that she is worried about damage to her spinal cord. The appropriate response from the nurse is which of the following? "The spinal cord ends at L1, so puncturing it is not possible." "Damage to the spinal cord is a possibility." "The physician is careful not to insert the needle far enough to reach the cord." "The needle is not long enough to damage the cord."
"The spinal cord ends at L1, so puncturing it is not possible." Explanation: The needle is usually inserted into the subarachnoid space between the 3rd and 4th or 4th and 5th lumbar vertebrae. Because the spinal cord ends at the 1st lumbar vertebra, insertion of the needle below the level of the 3rd lumbar vertebra prevents puncture of the spinal cord. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Lumbar Puncture and Examination of Cerebrospinal Fluid, p. 1969.
The nurse is caring for a patient who was involved in a motor vehicle accident and sustained a head injury. When assessing deep tendon reflexes (DTR), the nurse observes diminished or hypoactive reflexes. How will the nurse document this finding? 0 1+ 2+ 3+
1+ Explanation: Diminished or hypoactive DTRs are indicated by a score of 1+, no response by a score of 0, a normal response by a score of 2+, and an increased response by a score of 3+. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Chart 65-3, p. 1962.
The nurse is completing a neurologic assessment and uses the whisper test to assess which cranial nerve? Vagus Acoustic Facial Olfactory
Acoustic Explanation: Clinical examination of the acoustic nerve can be done by the whisper test. Having the client say "ah" tests the vagus nerve. Observing for symmetry when the client performs facial movements tests the facial nerve. The olfactory nerve is tested by having the client identify specific odors. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Table 65-2, p. 1952.
A client has sustained a head injury to the parietal lobe and cannot identify a familiar object by touch. The nurse knows that this deficit is Visual agnosia A positive Romberg Ataxia Astereognosis
Astereognosis Explanation: Astereognosis is the inability to identify an object by touch. Visual agnosia is the loss of ability to recognize objects through visualizing them. The Romberg test has to do with balance. Ataxia is defined as incoordination of voluntary muscle action. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Examining the Sensory System, p. 1962.
Lesions in the temporal lobe may result in which type of agnosia? Auditory Visual Tactile Relationship
Auditory Explanation: Lesions in the temporal lobe (lateral and superior portions) may result in auditory agnosia. Lesions in the occipital lobe may result in visual agnosia. Lesions in the parietal lobe may result in tactile agnosia. Lesions in the parietal lobe (posteroinferior regions) may result in relationship and body part agnosia. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Table 65-6, p. 1962.
The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve? CN I CN II CN III CN IV
CN I Explanation: Cranial nerve (CN) I is the olfactory nerve, which allows the sense of smell. Testing of CN I is done by having the patient identify familiar odors with eyes closed, testing each nostril separately. An inability to smell an odor is a significant finding, indicating dysfunction of this nerve. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Table 65-2, p. 1952.
The nurse is assessing the pupils of a patient who has had a head injury. What does the nurse recognize as a parasympathetic effect? Dilated pupils Constricted pupils One pupil is dilated and the opposite pupil is normal Roth's spots
Constricted pupils Explanation: Constricted pupils are a parasympathetic effect; dilated pupils are a sympathetic effect. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Table 65-3, p. 1955.
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? Cease function and shunt blood to the heart and lungs. Convert glycogen to glucose for immediate use. Produce a toxic byproduct in relation to stress. Maintain a basal rate of functioning.
Convert glycogen to glucose for immediate use. Explanation: When the body is under stress, the sympathetic nervous system is activated readying the body for action. The effect of the body is to mobilize stored glycogen to glucose to provide additional energy for body action. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Table 65-3: Effects of the Autonomic Nervous System, p. 1955.
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 I Cranial nerve V Cranial nerve XI Cranial nerve XII
Cranial nerve XII Explanation: Assessment of the movement of the tongue is related to cranial nerve XII, the hypoglossal nerve. Cranial nerve I is the olfactory nerve. Cranial nerve V is the trigeminal nerve responsible for sensation to the face and chewing. Cranial nerve XI is the spinal or accessory nerve responsible for head and shoulder and shoulder movement. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Table 65-2: Cranial Nerves, p. 1952.
If a client has a lower motor neuron lesion, the nurse would expect to observe which manifestation upon physical assessment? Hyperactive reflexes No muscle atrophy Muscle spasticity Decreased muscle tone
Decreased muscle tone Explanation: A client with a lower motor neuron lesion would be expected to have decreased muscle tone. Those with upper motor neuron lesion would have hyperactive reflexes, no muscle atrophy, and muscle spasticity. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, p. 1956.
Low levels of the neurotransmitter serotonin lead to which of the following disease processes? Depression Myasthenia gravis Seizures Parkinson's disease
Depression Explanation: A decrease of serotonin leads to depression. A decrease in the amount of acetylcholine causes myasthenia gravis. Parkinson's disease is caused by a depletion of dopamine. Decreased levels of GABA may cause seizures. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Table 65-1, p. 1947.
A patient has a deficiency of the neurotransmitter serotonin. The nurse is aware that this deficiency can lead to: Myasthenia gravis. Depression. Seizures. Parkinson's disease.
Depression. Explanation: Serotonin helps control mood and sleep. A deficiency leads to depression. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Table 65-1, p. 1947.
Which lobe of the brain is responsible for spatial relationships? Parietal Temporal Occipital Frontal
Parietal Explanation: The parietal lobe is essential to a person's awareness of body position in space, size and shape discrimination, and right-left orientation. The frontal lobe controls information storage or memory and motor function. The temporal lobe contains the auditory receptive area. The occipital lobe is responsible for visual interpretation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, p. 1948.
Which diagnostic test may be performed to evaluate blood flow within intracranial blood vessels? Computed tomography Magnetic resonance imaging Transcranial Doppler Cerebral angiography
Transcranial Doppler Explanation: Transcranial Doppler flow studies are used to study a tumor's blood flow within intracranial blood vessels. Cerebral angiography may be used to study a tumor's blood supply or obtain information about vascular lesions. Magnetic resonance imaging (MRI) provides information similar to that provided by computed tomography, with improved tissue contrast, resolution, and anatomic definition; MRI also examines the lesion in multiple planes. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, p. 1968.
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? II VI VIII XI
VIII Explanation: There are 12 pairs of cranial nerves. Cranial nerve VIII is the vestibulocochlear or auditory nerve responsible for hearing and balance. Cranial nerve II is the optic nerve. Cranial nerve VI is the abducens nerve responsible for eye movement. Cranial nerve XI is the accessory nerve and is involved with head and shoulder movement. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Table 65-2: Cranial Nerves, p. 1952.
During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to: use the pointed end of the reflex hammer when striking the Achilles tendon. support the joint where the tendon is being tested. tap the tendon slowly and softly. hold the reflex hammer tightly.
support the joint where the tendon is being tested. Explanation: The nurse should support the joint where the tendon is being tested to prevent the attached muscle from contracting. The nurse should use the flat, not pointed, end of the reflex hammer when striking the Achilles tendon. (The pointed end is used to strike over small areas, such as the thumb placed over the biceps tendon.) Tapping the tendon slowly and softly wouldn't provoke a deep tendon reflex response. The nurse should hold the reflex hammer loosely, not tightly, between the thumb and fingers so it can swing in an arc. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Deep Tendon Reflexes, p. 1962.
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: musculoskeletal system. sympathetic nervous system. parasympathetic nervous system. endocrine system.
sympathetic nervous system. Explanation: The division of the autonomic nervous system called the sympathetic nervous system regulates the expenditure of energy. The neurotransmitters of the sympathetic nervous system are called catecholamines. During an emergency situation or an intensely stressful event, the body adjusts to deliver blood flow and oxygen to the brain, muscles, and lungs that need to react in the situation. The musculoskeletal system benefits from the sympathetic nervous system as the fight-or-flight effects pump blood to the muscles. The parasympathetic nervous system works to conserve body energy not expend it during an emergency. The endocrine system regulates metabolic processes. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Sympathetic Nervous System, p. 1953.
A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure? Prone, with the head turned to the right Supine, with the knees raised toward the chest Lateral recumbent, with thighs flexed Lateral, with right leg flexed
Lateral recumbent, with thighs flexed Explanation: To maximize the space between the vertebrae, the client is placed in a lateral recumbent position with the thighs flexed toward the chin as much as possible. The needle is inserted between L4 and L5. The positions in the other answer choices would not allow as much space between L4 and L5. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Chart 65-4, p. 1970.
A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with: body temperature control. balance and equilibrium. visual acuity. thinking and reasoning.
body temperature control. Explanation: The body's thermostat is located in the hypothalamus; therefore, injury to that area can cause problems with body temperature control. Balance and equilibrium problems are related to cerebellar damage. Visual acuity problems would occur following occipital or optic nerve injury. Thinking and reasoning problems are the result of injury to the cerebrum. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Autonomic Nervous System, p. 1952.
Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed? Ataxia Clonus Rigidity Flaccidity
Clonus Explanation: Clonus occurs when the foot is abruptly dorsiflexed. It continues to "beat" two or three times before it settles into a position of rest. Sustained clonus always indicates the present of central nervous system disease and requires further evaluation. Ataxia is incoordination of voluntary muscle action. Rigidity is an increase in muscle tone at rest characterized by increased resistance to passive movement. Flaccid posturing is usually the result of lower brain stem dysfunction; the client has no motor function, is limp, and lacks motor tone. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, p. 1964.
A patient has been diagnosed with damage to Broca's area of the left frontal lobe. To document the extent of damage, the nurse would assess the patient's: Speech. Vision. Hearing. Balance.
Speech. Explanation: The motor strip, which lies in the frontal lobe, anterior to the central sulcus, is responsible for muscle movement. It also contains Broca's area (left frontal lobe region in most people), critical for motor control of speech. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Cerebrum, p. 1948.
Which cerebral lobe contains the auditory receptive areas? Frontal Parietal Occipital Temporal
Temporal Explanation: The temporal lobe plays the most dominant role of any area of the cortex in cerebration. The frontal lobe, the largest lobe, controls concentration, abstract thought, information storage or memory, and motor function. The parietal lobe contains the primary sensory cortex, which analyzes sensory information and relays interpretation to the thalamus and other cortical areas. The occipital lobe is responsible for visual interpretation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Table 65-5, p. 1959.
What is the function of cerebrospinal fluid (CSF)? It cushions the brain and spinal cord. It acts as an insulator to maintain a constant spinal fluid temperature. It acts as a barrier to bacteria. It produces cerebral neurotransmitters.
It cushions the brain and spinal cord. Explanation: CSF is produced primarily in the lateral ventricles of the brain. It acts as a shock absorber and cushions the spinal cord and brain against injury caused by sudden or extreme movement. CSF also functions in the removal of waste products from cerebral tissue. CSF doesn't act as an insulator or a barrier and it doesn't produce cerebral neurotransmitters. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Cerebrospinal Fluid, p. 1950.
A nurse is discussing a lumbar puncture with a nursing student who observed the procedure. The student noticed that the cerebrospinal fluid was blood tinged and asks what that means. The correct reply is which of the following? "It can mean a traumatic puncture or a subarachnoid bleed." "It can mean a bleed around the hypothalamus or damage from the needle." "It can mean the spinal cord was damaged or a traumatic puncture." "It can mean a subarachnoid bleed or damage to the spinal cord."
"It can mean a traumatic puncture or a subarachnoid bleed." Explanation: The needle is inserted below the level of the spinal cord, which prevents damage to the cord. The cerebral spinal fluid (CSF) should be clear and colorless. Pink or bloody CSF may indicate a subarachnoid bleed or local trauma from the puncture. The hypothalamus is located deep inside the brain and does not affect the color of the CSF. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Cerebrospinal Fluid Analysis, p. 1969.
A 53-year-old man presents to the emergency department with a chief complaint of inability to form words, and numbness and weakness of the right arm and leg. Where would you locate the site of injury? Left frontoparietal region Right frontoparietal region Left basal ganglia Left temporal region
Left frontoparietal region Explanation: The patient is exhibiting signs of expressive aphasia with numbness/tingling and weakness of the right arm and leg. This indicates injury to the expressive speech center (Broca's area), which is located in the inferior portion of the frontal lobe. The motor strip is located in the posterior portion of the frontal lobe. The sensory strip is located in the anterior parietal lobe. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Cerebrum, p. 1948.
Which of the following areas of the brain are responsible for temperature regulation? Hypothalamus Thalamus Pons Medulla
Hypothalamus Explanation: The hypothalamus also controls and regulates the autonomic nervous system and maintains temperature by promoting vasoconstriction or vasodilation. The thalamus acts primarily as a relay station for all sensation except smell. The medulla and pons are essential for respiratory function. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Cerebrum, p. 1948.
During a neurological assessment examination, the nurse assesses a patient for tactile agnosia. The nurse places a familiar door key in the patient's hand and asks him to identify the object with his eyes closed. The nurse documents his inability to identify the object and notes the affected area of the brain. Which of the following is the most likely affected area of the brain? Occipital lobe Temporal lobe Parietal lobe Frontal lobe
Parietal lobe Explanation: The parietal lobe analyzes sensor information and relays the interpretation to the cortical area. Failure to identify a familiar object by touch is indicative of parietal lobe dysfunction. Refer to Table 43-7 in the text. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Cerebrum, p. 1948.
The nurse has completed evaluating the client's cranial nerves. The nurse documents impairment of the right cervical nerves (CN IX and CN X). Based on these findings, the nurse should instruct the client to refrain from eating or drinking for now. have their spouse bring in the client's glasses. wear any hearing aids while in the hospital. use the walker when walking.
refrain from eating or drinking for now. Explanation: Significant findings of CN IX (glossopharyngeal) include difficulty swallowing (dysphagia) and impaired taste, and significant findings of CN X (vagus) include weak or absent gag reflex, difficulty swallowing, aspiration, hoarseness, and slurred speech (dysarthria). Based on these findings, the nurse should instruct the client to refrain from eating and drinking and should contact the health care provider. The other instructions are associated with abnormalities of CN II (optic) and CN VIII (acoustic). Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Table 65-2, p. 1952.
Which is a sympathetic effect of the nervous system? Decreased blood pressure Increased peristalsis Dilated pupils Decreased respiratory rate
Dilated pupils Explanation: Dilated pupils are a sympathetic effect of the nervous system, whereas constricted pupils are a parasympathetic effect. Decreased blood pressure is a parasympathetic effect, whereas increased blood pressure is a sympathetic effect. Increased peristalsis is a parasympathetic effect, but decreased peristalsis is a sympathetic effect. Decreased respiratory rate is a parasympathetic effect, and increased respiratory rate is a sympathetic effect. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Table 65-3, p. 1955.
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? Identification of information due to slowed passages of information to brain. Cognitive ability to understand relayed information. Processing information transferred from the environment. Response due to interrupted impulses from the central nervous system
Response due to interrupted impulses from the central nervous system Explanation: The central nervous system is composed of the brain and the spinal cord. Motor neurons transmit impulses from the central nervous system. Slowing transmission in this area would slow the response of transmission leading to a delay in reaction. Sensory neurons transmit impulses from the environment to the central nervous system, allowing identification of a stimulus. Cognitive centers of the brain interpret the information. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 65: Assessment of Neurological Function, p. 1948. Chapter 65: Assessment of Neurologic Function - Page 1948
A client preparing to undergo a lumbar puncture states he doesn't think he will be able to get comfortable with his knees drawn up to his abdomen and his chin touching his chest. He asks if he can lie on his left side. Which statement is the best response by the nurse? "Lying on your left side will be fine during the procedure." "There's no other option but to assume the knee-chest position." "Although the required position may not be comfortable, it will make the procedure safer and easier to perform." "I'll report your concerns to the physician."
"Although the required position may not be comfortable, it will make the procedure safer and easier to perform." Explanation: The nurse should explain that the knee-chest position is necessary to make the procedure safer and easier to perform. Lying on his left side won't make the procedure easy or safe to perform. The nurse shouldn't simply tell the client there is no other option because the client is entitled to understand the rationale for the required position. Reporting the client's concerns to the physician won't meet the client's needs in this situation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Lumbar Puncture and Examination of Cerebrospinal Fluid, p. 1969.
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? Myelogram Electroencephalogram Echoencephalography Cerebral angiography
Cerebral angiography Explanation: The nurse would anticipate a cerebral angiography, which detects distortion of the cerebral arteries and veins . A myelogram detects abnormalities of the spinal canal. An electroencephalogram records electrical impulses of the brain. An echoencephalography is an ultrasound of the structures of the brain. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Cerebral Angiography, p. 1967.
A nurse is working in a neurologist's office. The physician orders a Romberg test. What should the nurse instruct the client to do? Touch nose with one finger. Close eyes and stand erect. Close eyes and discriminate between dull and sharp. Close eyes and jump on one foot.
Close eyes and stand erect. Explanation: In the Romberg test, the client stands erect with the feet close together and eyes closed. If the client sways as if to fall, it is considered a positive Romberg test. All of the other options include components of neurologic tests, indicating neurologic deficits and balance. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Balance and Coordination, p. 1961.
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 isslowing transmission of the motor neurons, in what would the nurse anticipate a delayed reaction? Identification of information due to slowed passages of information to brain. Cognitive ability to understand relayed information. Processing information transferred from the environment. Response due to interrupted impulses from the central nervous system
Response due to interrupted impulses from the central nervous system Explanation: The central nervous system is composed of the brain and the spinal cord. Motor neurons transmit impulses from the central nervous system. Slowing transmission in this area would slow the response of transmission leading to a delay in reaction. Sensory neurons transmit impulses from the environment to the central nervous system, allowing identification of a stimulus. Cognitive centers of the brain interpret the information. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 65: Assessment of Neurological Function, p. 1948.
After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an: evaluation of the corneal reflex response. examination of the fundus of the eye. assessment of the client's gait. evaluation of bowel and bladder functions.
evaluation of the corneal reflex response. Explanation: During an acute crisis, the nurse should check the corneal reflex response to rapidly assess brain stem function. Other components of the brief initial neurologic assessment usually include level of consciousness, pupillary response, and motor response in the arms and legs. If appropriate and if time permits, the nurse also may assess sensory responses of the arms and legs. Emergency assessment doesn't include fundus examination unless the client has sustained direct eye trauma. The client shouldn't be moved unnecessarily until the extent of injuries is known, making gait evaluation impossible. Bowel and bladder functions aren't vital, so the nurse should delay their assessment. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Superficial Reflexes, p. 1964.
A patient sustained a head injury during a fall and has changes in personality and affect. What part of the brain does the nurse recognize has been affected in this injury? Frontal lobe Parietal lobe Occipital lobe Temporal lobe
Frontal lobe Explanation: The frontal lobe, the largest lobe, located in the front of the brain. The major functions of this lobe are concentration, abstract thought, information storage or memory, and motor function. It contains Broca's area, which is located in the left hemisphere and is critical for motor control of speech. The frontal lobe is also responsible in large part for a person's affect, judgment, personality, and inhibitions (Hickey, 2009). Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Cerebrum, p. 1948.
A patient arrives to have an MRI done in the outpatient department. What information provided by the patient warrants further assessment to prevent complications related to the MRI? "I am trying to quit smoking and have a patch on." "I have been trying to get an appointment for so long." "I have not had anything to eat or drink since 3 hours ago." "My legs go numb sometimes when I sit too long."
"I am trying to quit smoking and have a patch on." Explanation: Before the patient enters the room where the MRI is to be performed, all metal objects and credit cards (the magnetic field can erase them) must be removed. This includes medication patches that have a metal backing and metallic lead wires; these can cause burns if not removed (Bremner, 2005). Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Nursing Interventions, p. 1966.
A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction? "Don't eat anything for 12 hours before the test." "Don't shampoo your hair for 24 hours before the test." "Avoid stimulants and alcohol for 24 to 48 hours before the test." "Avoid thinking about personal matters for 12 hours before the test."
"Avoid stimulants and alcohol for 24 to 48 hours before the test." Explanation: For 24 to 48 hours before an EEG, the client should avoid coffee, cola, tea, alcohol, and cigarettes because these may interfere with the accuracy of test results. (For the same reason, the client also should avoid antidepressants, sedatives, and anticonvulsants.) To avoid a reduced serum glucose level, which may alter test results, the client should eat normal meals before the test. The hair should be washed before an EEG because the electrodes must be applied to a clean scalp. The client's thoughts don't affect the test results. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Nursing Interventions, p. 1968.
The nurse is assessing the client's mental status . Which question will the nurse include in the assessment? "Who is the president of the United States?" "Can you write your name on this piece of paper?" "Can you count backward from 100?" "Are you having hallucinations now?"
"Who is the president of the United States?" Explanation: Assessing orientation to time, place, and person assists in evaluating mental status. Does the client know what day it is, what year it is, and the name of the president of the United States? Is the client aware of where he or she is? Is the client aware of who the examiner is and why he or she is in the room? "Can you write your name on this piece of paper?" will assess language ability. "Can you count backward from 100?" assesses the client's intellectual function. "Are you having hallucinations?" assesses the client's thought content. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, p. 1959.
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) Magnetic resonance imaging (MRI) Positron emission tomography (PET) Single-photon emission computed tomography (SPECT)
Computed tomography (CT) Explanation: A computer tomography scan uses x-rays and computer analysis to produce three-dimensional views of cross sections, or "slices," of the body. An MRI uses radiofrequency waves to produce images of tissue. PET scans use radioactive substances to examine metabolic activity and organ involvement. SPECT is an imaging tool that examines cerebral blood flow. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Computed Tomography Scanning, p. 1965.
A nurse is completing a neurological assessment and determines that the client has significant visual deficits. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit? frontal parietal temporal occipital
occipital Explanation: The vision center is located in the occipital lobe. There is little that may interfere with the visual process in the other lobes of the brain. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 65: Assessment of Neurological Function, p. 1948.
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. The nurse should tell the client: not to worry about the finer details of the disease. that because there is so much to learn, there will be another meeting to discuss it again. that the covering is called myelin and that it can be discussed further at the next meeting. that the disease process requires more research.
that the covering is called myelin and that it can be discussed further at the next meeting. Explanation: Myelin is a fatty substance that covers some axons in the CNS and PNS. The nurse would be most correct in answering the question and then, if the client is tired, following up at the next meeting. It would also be appropriate to provide literature for the client to review at leisure. Discounting the client's need to know information about the disease process is belittling. Telling the client that more research needs to be done discounts the valuable information which is known. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Multiple Sclerosis, p. 2072.
A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by: introducing ice water into the external auditory canal. touching the cornea with a wisp of cotton. turning the client's head suddenly while holding the eyelids open. shining a bright light into the pupil.
turning the client's head suddenly while holding the eyelids open. Explanation: To elicit the oculocephalic response, which detects cranial nerve compression, the nurse turns the client's head suddenly while holding the eyelids open. Normally, the eyes move from side to side when the head is turned; in an abnormal response, the eyes remain fixed. The nurse introduces ice water into the external auditory canal when testing the oculovestibular response; normally, the client's eyes deviate to the side of ice water introduction. The nurse touches the client's cornea with a wisp of cotton to elicit the corneal reflex response, which reveals brain stem function; blinking is the normal response. Shining a bright light into the client's pupil helps evaluate brain stem and cranial nerve III function; normally, the client's pupil responds by constricting. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Level of Consciousness, p. 1959.
A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first? Maintain the client NPO for 6 hours before the test. Obtain a blood sample to evaluate BUN and creatinine concentrations. Assess the client for medication allergies. Obtain two large-bore IV lines.
Assess the client for medication allergies. Explanation: If a contrast agent is used, the client must be assessed before the CT scan for an iodine/shellfish allergy, because the contrast agent used may be iodine based. If the client has no allergies to iodine, then kidney function must also be evaluated, as the contrast material is cleared through the kidneys. A suitable IV line for contrast injection and a period of fasting (usually 4 hours) are required before the study. Clients who receive an IV contrast agent are monitored during and after the procedure for allergic reactions and changes in kidney function. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, p. 1966.
Which of the following is a sympathetic nervous system effect? Decreased peristalsis Decreased blood pressure Constricted pupils Constricted bronchioles
Decreased peristalsis Explanation: Sympathetic effects of the nervous system include decreased peristalsis, increased blood pressure, dilated pupils, and dilated bronchioles. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Sympathetic Nervous System, p. 1953.
A male client is scheduled for an electroencephalogram (EEG). When the nurse caring for the client is preparing him for the test, the client states that during childhood he was mildly electrocuted but miraculously lived. Therefore, he is quite afraid of going through an EEG. In what ways can the nurse help dispel the client's fear regarding the test? Distract the client's attention from the test. Inform the client that he will not experience any electrical shock. Inform the client that he will experience only mild electrical shock. Encourage adequate water intake by the client.
Inform the client that he will not experience any electrical shock. Explanation: An EEG records the electrical impulses generated by the brain. To prepare the client for the test, the nurse informs the client that he or she will not experience any electrical shock. The source of electrical energy is the client's neural activity within the brain and not any external electrical energy. Ensuring adequate water intake or distracting the attention of the client will not comfort the client about the technical nature of the test. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Electroencephalography, p. 1968.
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 toward both sides Lightly tapping the lower portion of the neck to detect sensation Moving the head and chin toward the chest Gently pressing the bones on the neck
Moving the head and chin toward the chest Explanation: The neck is examined for stiffness or abnormal position. The presence of rigidity is assessed by moving the head and chin toward the chest. The nurse should not maneuver the neck if a head or neck injury is suspected or known. The neck should also not be maneuvered if trauma to any part of the body is evident. Moving the head toward the sides or pressing the bones on the neck will not help assess for neck rigidity correctly. While assessing for neck rigidity, sensation at the neck area is not to be assessed. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018.
A client is scheduled for standard EEG testing to evaluate a possible seizure disorder. Which nursing intervention should the nurse perform before the procedure? Withhold anticonvulsant medications for 24 to 48 hours before the exam Maintain NPO status for 6 hours before the procedure Sedate the client before the procedure, per orders Instruct the client that a standard EEG takes 2 hours
Withhold anticonvulsant medications for 24 to 48 hours before the exam Explanation: Anticonvulsant agents, tranquilizers, stimulants, and depressants should be withheld 24 to 48 hours before an EEG because these medications can alter EEG wave patterns or mask the abnormal wave patterns of seizure disorders. To increase the chances of recording seizure activity, it is sometimes recommended that the client be deprived of sleep on the night before the EEG. Coffee, tea, chocolate, and cola drinks are omitted in the meal before the test because of their stimulating effect. However, meals are not omitted, because an altered blood glucose concentration can cause changes in brain wave patterns. The client is informed that a standard EEG takes 45 to 60 minutes; a sleep EEG requires 12 hours. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, p. 1968.