Med-Surg Ch. 21 The Neurological System

Aphasia

A defect in the ability to express oneself in speech or writing, or an inability to comprehend spoken or written language.

Babinski reflex

A reflex action elicited by stimulating the sole of the foot and characterized by dorsiflexion of the great toe and flaring of the smaller toes. Positive Babinski reflex indicates abnormality in the motor control pathways of the nervous system.

Calculi

An abnormal concentration, usually of mineral salts, occurring mainly in hollow organs or the passages (e.g., renal calculus, or kidney stone).

Caloric testing

Testing to check the oculovestibular reflex. A patient's eye movements are observed while the external ear canal is irrigated with cold water. Absence of eye movement indicates a brainstem lesion.

Accommodation

The process by which the eye's lens changes shape to focus near or far objects on the retina

Why is the Glasgow Coma Scale used by the nurse while performing an assessment of a traumatized client? 1. To assess patency of airway 2. To assess level of consciousness 3. To assess breathing abnormalities 4. To assess circulatory abnormalities

2. To assess level of consciousness

Delirium

An altered state of consciousness that is usually acute and of short duration.

Decerebrate posturing

Extensor posturing; the arms are stiffly extended and held close to the body and the wrists are flexed outward. Indicates damage to the midbrain or brainstem.

Decorticate posturing

Flexor posturing; extension of the legs and internal rotation and adduction of the arms with the elbows bent upward. Indicates damage to the cortex.

Which type of seizure occurs during childhood and adolescence and rarely continues after adolescence? 1. Partial 2. Absence 3. Myoclonic 4. Generalized tonic-clonic

2. Absence Absence seizures occur during childhood and adolescence and rarely continue after adolescence

A client is experiencing both tingling of the extremities and tetany. What should the nurse anticipate will be prescribed by the health care provider? 1. Dialysis 2. Calcium supplements 3. Mechanical ventilation 4. Intravenous fluids with potassium

2. Calcium supplements Tingling extremities and tetany are signs of hypocalcemia, which is corrected by the administration of calcium

What therapeutic effect does the nurse expect to identify when mannitol is administered parenterally to a client with cerebral edema? 1. Improved renal blood flow 2. Decreased intracranial pressure 3. Maintenance of circulatory volume 4. Prevention of the development of thrombi

2. Decreased intracranial pressure As an osmotic diuretic, mannitol helps reduce cerebral edema.

A client with arthritis is taking ibuprofen, a nonsteroidal anti-inflammatory drug, and large doses of aspirin. The nurse teaches the client about the clinical manifestations of aspirin toxicity, including what? 1. Feeling of drowsiness 2. Disturbances in hearing 3. Intermittent constipation 4. Metallic taste in mouth

2. Disturbances in hearing Ringing in the ears occurs because of its effect on the eighth cranial nerve and is a classic symptom of aspirin toxicity

What clinical finding does the nurse expect when assessing a client with myasthenia gravis? 1. Partial improvement of muscle strength with mild exercise 2. Fluctuating weakness of muscles innervated by the cranial nerves 3. Dramatic worsening in muscle strength with anticholinesterase drugs 4. Minimal changes in muscle strength regardless of the therapy initiated.

2. Fluctuating weakness of muscles innervated by the cranial nerves Myasthenia gravis s a chronic disorder of muscles enervated by weakened cranial nerves; eyelid movement, chewing, swallowing, speech, facial expression, and breathing often are affected

A client is treated with lorazepam for status epilepticus. What effect of lorazepam does the nurse consider therapeutic? 1. Slow cardiac contractions 2. Dilates tracheobronchial structures 3. Depresses the central nervous system (CNS) 4. Provides amnesia for the convulsive episode

3. Depresses the CNS system Lorazepam, an anxiolytic and sedative, is used to treat status epilepticus because it depresses the CNS

A nurse begins planning for the discharge of a client who had a brain attack (CVA) with residual hemiparesis and hemianopsia. What information should the nurse include in the discharge teaching plan for this client? 1. Necessity for bed rest at home 2. Use of oxygen therapy at home 3. Significance of a safe environment 4. Need for decreased protein in the die

3. Significance of a safe environment Safety becomes a priority when the client has hemiparesis and hemianopia

A client with expressive aphasia becomes agitated and upset when attempting to communicate with the nurse. To help reduce the client's frustration, what should the nurse do? 1. Limit the clients contact with others to minimize communication attempts 2. Anticipate needs so the client does not need to ask for help 3. Face the client while speaking loudly 4. Allow the client adequate time to speak

4. Allow the client adequate time to speak

Which desired effect of therapy should the nurse explain to the client who has primary angle-closure glaucoma? 1. Dilating the pupil 2. Resting the eye muscles 3. Preventing secondary infection 4. Controlling intraocular pressure

4. Controlling intraocular pressure Glaucoma is a disease in which there is increased intraocular pressure resulting from narrowing of the aqueous outflow channel (canal of Schlemm). This can lead to blindness, caused by compression of the nutritive blood vessels supplying the rods and cones

What clinical indicator does the nurse expect to identify when assessing a client with a brain tumor in the occipital lobe? 1. Hemiparesis 2. Receptive aphasia 3. Personality changes 4. Visual hallucinations

4. Visual hallucinations The occipital lobe is involved with visual interpretation.

Clonus

Abnormal neuromuscular activity, characterized by rapidly alternating involuntary contraction and relaxation of skeletal muscle; occurs with epileptic seizure.