Med Surg II Exam 1

The book calls neurons which function as a link between different types of neurons is called

interneuron

It receives, stores, ______________ and sends information.

interprets

Each axon that is surrounded by myelin is said to be ________________.

myelinated

Which lobe of the brain is responsible for temperature?

parietal lobe

Each neuron has only ______ axon.

1

The pressure of CFS reflects:

>brain injury such as bleeding, tumors, swelling, or infection >ICP

A client sustains a head trauma after falling from a roof. The nurse observes clear fluid leaking from the nose. What is the priority action by the nurse? a. Use a Q-tip to gently clean the nasal passages. b. Pack the nose with nasal packing. c. Have the client blow the nose to clear the passages. d. Have the fluid checked for glucose.

Answer: d Cognitive Level: Analyze Explanation: If a client sustains head trauma and fluid is noted leaking from the ears or nose, this fluid should be tested for glucose, which is present in CSF. If the glucose test is positive, notify a healthcare provider immediately, because leaking CSF usually indicates a life-threatening situation.

An axon is an extension which carries impulses _________ from the nerve.

away

The nervous system functions as a ___________________ and _______________ ______________for the body.

communication and control center

Which is a function of the parasympathetic system?

erection

_________________ connective tissue surrounds each entire nerve.

Epineurium

The cell body must be near the axon and dendrites.

False

____ ________ and blood vessels surround nerve fascicles, wrapped in perineurium.

Fat tissue

If a nerve cell body is destroyed, how long does it take to reproduce?

It doesn't

The gap between Schwann cells is called

Node of Ranvier

Myelin is formed by plasma membranes of ______________ _________, which provide nutrition and support.

Schwann cells

The trigeminal nerve controls

Sensation of head and face

The cerebral cortex is divided into four lobes.

True

The nerve signal is either all transmitted or not transmitted, this is the

all-or-none law

Myelin is a _________ sheath, which electrically insulates one nerve cell from another.

fatty

The B in the sensory mnemonic means

both

In addition, each neuron contains two process (one axon and many _______________).

dendrites

The inner most layer, __________________, wraps individual axons.

endoneurium

Stimulation of what nerve can cause a dangerous drop in heart rate?

vagal

The nurse is requested to place an ice pack on the eyelid for 2 minutes for a client suspected of having myasthenia gravis (MG) with diplopia. What outcome does the nurse anticipate if the diagnosis is confirmed? a. The client will have an improvement in respiratory status. b. The client will have blindness. c. The client will have a grave prognosis. d. The client will have a temporary improvement in eye symptoms.

Answer: d Cognitive Level: Apply Explanation: An ice pack test is a noninvasive method of testing for MG. If the client has diplopia, an ice pack over the eyelid for 2 minutes will result in improvement of eye symptoms. The ice pack will not improve respiratory status. It is not an indication that the client will experience blindness or that the prognosis is grave.

It can be as short as a few _______________ or it may be longer than a meter.

millimeters

The nurse is caring for a client with herpes zoster. What priority measures to avoid cross-contamination should the nurse provide? a. Use transmission-based precautions. b. Administer antiviral medications as ordered. c. Apply antihistamine cream to the lesions. d. Have the client wear gloves.

Answer: a Cognitive Level: Apply Explanation: With herpes zoster, infection control measures are necessary to prevent cross-contamination. It is possible for individuals who have never had chickenpox to develop chickenpox from contact with someone with shingles. Transmission-based precautions are necessary. All healthcare providers should avoid touching the lesions directly. The nurse should always wear gloves whenever there is a possibility of exposure to drainage and secretions. It is not necessary for the client to wear gloves. Antiviral medication will be prescribed for the client to reduce the symptoms but does not reduce the risk of transmission to others. Antihistamine cream will not prevent cross-contamination.

A client with chronic alcoholism and late stage cirrhosis of the liver has significant damage to Wernicke's area. What data obtained by the nurse is indicative of this damage? a. The client is unable to ambulate independently. b. The client does not comprehend written and spoken language but speaks. c. The client has speech impairment, but is able to comprehend language. d. The client's left hand is experiencing paralysis.

Answer: b Cognitive Level: Analyze Explanation: Damage to Wernicke's area in the brain impairs the client's ability to comprehend written and spoken language, but the client is still able to speak.

A client with a T6 injury reports a pounding headache, blurred vision, and nasal congestion. The nurse observes profuse sweating above the level of injury. What is the priority action by the nurse? a. Irrigate the client's indwelling catheter. b. Elevate the client's head. c. Place the client in Trendelenburg position. d. Obtain the client's temperature.

Answer: b Cognitive Level: Analyze Explanation: Sudden, significant increase in blood pressure (systolic and diastolic) of 20 to 40 mm Hg above baseline; sudden onset of a pounding headache, bradycardia, arrhythmias, profuse sweating (diaphoresis), goose bumps (piloerection), and flushing above the level of injury, blurred vision, or spots in the visual field, nasal congestion, apprehension, anxiety are all symptoms of autonomic dysreflexia. Autonomic dysreflexia is a medical emergency that requires prompt treatment. The first action that should be taken is to elevate the head of the bed. Irrigation of the indwelling catheter is not necessary and will not alleviate the problem. Trendelenburg position is not an appropriate intervention. Obtaining the client's temperature should not be done before elevating the head of the bed.

The nurse is reinforcing education for a female client paralyzed from a spinal cord injury (SCI). What statement made by the client demonstrates understanding of the education? a. "I may begin to menstruate within 3 months following my injury." b. "I should use birth control pills as a means of contraception." c. "It is just as safe for me to become pregnant as a woman without an SCI." d. "I should use a tampon instead of a feminine pad when I am menstruating."

Answer: a Cognitive Level: Analyze Explanation: Menses usually resume within 3 months following the injury. It takes time for the body to adjust to the injury. The use of birth control pills is not recommended. They can lead to thrombus formation, particularly if the client is not exercising or is immobile. Effectiveness often decreases because of interactions with other medications. Labor and childbirth may be dangerous. The woman may not be aware of the onset of labor. The likelihood of a cesarean birth is increased because the woman may not be able to assist with the delivery and the uterus may not have adequate muscle tone. In addition, labor and delivery may serve as a trigger for autonomic dysreflexia. The use of tampons is not recommended because the woman may forget that a tampon is in place because she has no sensation.

A client suffers a stroke located in the medulla. What is the priority action by the nurse? a. Support the client's respiratory function. b. Assist the client with ambulation. c. Orient the client to surroundings frequently. d. Monitor the client for swallowing food and fluid.

Answer: a Cognitive Level: Analyze Explanation: The medulla contains centers for many vital body functions, including the cardiac center (regulates heart rate), vasomotor center (regulates the diameter of blood vessels, thereby regulating blood pressure), and respiratory center (regulates breathing). Other activities of the medulla are concerned with reflexes, such as swallowing, coughing, sneezing, hiccupping, and vomiting. Although all of the options are important nursing interventions, the priority action would be the support of the respiratory system. Since the affected area is in the medulla, if the respiratory system is not supported by artificial means such as a bag-valve-mask or a mechanical ventilator, the client will not be able to sustain life. The client will not be able to ambulate or swallow food and fluid and will require enteral feedings. Orientation is part of nursing interventions even though the client most likely will be comatose.

A client who sustained head trauma in a motor vehicle crash is determined to have an increase in intracranial pressure (ICP). What related complications should the nurse be aware of? Select all that apply. a. Brain hypoxia b. Herniation of the brain c. Brain compression d. Paralysis of the lower extremities e. Urinary retention

Answer: a, b, c Cognitive Level: Apply Explanation: The skull is a rigid container that contains brain tissue, CSF, and blood. The volume of these components determines ICP. A large increase in any of these factors can increase ICP. This can cause brain hypoxia (oxygen deprivation), herniation of the brain (brain contents being pushed through an opening), brain compression (the brain is pushed against the rigid skull), necrosis (death) of brain tissue in a specific area, or death of the individual.

The nurse witnesses a client having a tonic-clonic seizure in the bed. What is the priority action by the nurse? a. Insert a tongue blade between the client's teeth. b. Place the client in the prone position. c. Turn the head to the side. d. Insert an indwelling catheter.

Answer: c Cognitive Level: Apply Explanation: The priority action by the nurse would be to turn the client's head to the side to avoid aspiration. The nurse should not attempt to place anything in between the client's teeth because it may damage the oral mucosa and break teeth. The tongue blade may splinter and be aspirated. The client should not be placed in the prone position because the airway cannot be protected in that position. It is unnecessary to insert a catheter into the client for urinary drainage even if the client voids incontinently during the seizure.

A client is having a colonoscopy and suddenly the client's heart rate drops from 72 beats per minute (BPM) to 52 BPM. What cranial nerve does the nurse determine has been stimulated? a. Cranial Nerve I (Olfactory) b. Cranial Nerve V (Trigeminal) c. Cranial Nerve IX (Glossopharyngeal) d. Cranial Nerve X (Vagus)

Answer: d Cognitive Level: Analyze Explanation: Branches of the vagus nerve innervate muscles of the pharynx, larynx, respiratory tract, heart, esophagus, and parts of the abdominal viscera. Therefore, the vagus nerve has reflex control of heart rate, sneezing, hunger, secretions from glands in the stomach, and constrictions within the respiratory tract. If the client's heart rate has dropped then it is likely that cranial nerve X, the vagus nerve, has been stimulated.

The ANS (Autonomic Nervous System):

Functions independently innervating organs not under voluntary control

Neurons influence thinking, ___________ ____________, and regulate organs and glands.

affect memory

A nerve resembles a MUSCLE CELL with many branches becoming smaller and smaller and forming the _______.

axon

A client presents to the ER with slurred speech and difficulty moving his left arm. You suspect the client is having....

cerebral cortex CVA

Which part of the brain is considered "the seat of consciousness"

cerebrum

The dura mater, arachnoid membrane, and pia mater are

meninges

Ingest and destroy microorganisms and wastes

microglia

A neuron has only one CELL BODY, which contains the nucleus, ____________________, and other organelles.

mitochondria

Many neurons make up a ___________, which contains axons bundled into groups.

nerve

The basic structural and functional cell of the nervous system is the

neuron

A chemical released by the axon enabling nerve impulses to cross the synapse

neurotransmitter

A molecule that is released by the axon of the nerve in order to send a signal is a

neurotransmitter

Which part of the brain is the center composed of billions of axons and dendrites?

white matter

A positive or negatively charged molecule is called an

ion