MSII Prep U Ch. 65 Assessment of Neurologic Function

A nurse is preparing a client for a lumbar puncture. The client has heard about post-lumbar puncture headaches and asks what causes them. The nurse tells the client that these headches are caused by which of the following?

Cerebral spinal fluid leakage at the puncture site The headache is caused by cerebral spinal fluid (CSF) leakage at the puncture site. The supply of CSF in the cranium is depleted so that there is not enough to cushion and stabilize the brain. When the client assumes an upright position, tension and stretching of the venous sinuses and pain-sensitive structures occur.

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. 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.

Lesions in the temporal lobe may result in which of the following types of agnosia?

Auditory 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.

Which of the following terms refer to a method of recording, in graphic form, the electrical activity of the muscle?

Electromyogram Electromyogram is a method of recording, in graphic form, the electrical activity of the muscle. Electroencephalogram is a method of recording, in graphic form, the electrical activity of the brain. Electrocardiography is performed to assess the electrical activity of the heart. Electrogastrography is an electrophysiologic study performed to assess gastric motility disturbances.

Lower motor neuron lesions cause

flaccid muscle paralysis. Lower motor neuron lesions cause flaccid muscle paralysis, 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

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?

occipital 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.

Which of the following cranial nerves is responsible for muscles that move the eye and lid?

Oculomotor 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 (VII) cranial nerve is responsible for hearing and equilibrium. The facial (VII) nerve is responsible for salivation, tearing, taste, and sensation in the ear.

Which of the following safety actions will the nurse implement for a patient receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)?

Ensure that no patient care equipment containing metal enters the room where the MRI table is located. For patient safety, the nurse must make sure that no patient care equipment (eg, portable oxygen tanks) that contains metal or metal parts enters the room where the MRI is located. The patient must be assessed for the presence of medication patches with foil backing (e.g., nicotine) that may cause a burn. 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.

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?

Cerebral angiography 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.

A patient is having a lumbar puncture and the physician has removed 20 mL of cerebrospinal fluid. What nursing intervention is a priority after the procedure?

Have the patient lie flat for 6 hours. Post-lumbar puncture headache may be avoided if a small-gauge needle is used and if the patient remains prone after the procedure. When more than 20 mL of CSF is removed, the patient is positioned supine for 6 hours (Bader & Littlejohns, 2010).

A patient recently noted difficulty maintaining his balance and controlling fine movements. The nurse explains that the provider will order diagnostic studies for the part of his brain known as the:

Cerebellum. The cerebellum is largely responsible for coordination of all movement. It also controls fine movement, balance, position (postural) sense or proprioception (awareness of where each part of the body is), and integration of sensory input.

The nurse is preparing a client for a neurological examination by the physician and explains tests the physician will be doing, including the Romberg test. The client asks the purpose of this particular test. The correct reply by the nurse is which of the following?

"It is a test for balance." The Romberg test screens for balance. The client stands with feet together and arms at the side, first with eyes open and then with both eyes closed for 20 to 30 seconds. Slight swaying is normal, but a loss of balance is abnormal and is considered a positive Romberg test.

To evaluate a client's cerebellar function, a nurse should ask:

"Do you have any problems with balance?" 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.

Which lobe of the brain is responsible for concentration and abstract thought?

Frontal The major functions of the frontal lobe are concentration, abstract thought, information storage or memory, and motor function. The parietal lobe analyzes sensory information such as pressure, vibration, pain, and temperature. The occipital lobe is the primary visual cortex. The temporal lobe contains the auditory receptive areas located around the temples.

Low levels of the neurotransmitter serotonin lead to which of the following disease processes?

Depression 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.

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 Pinpoint pupils Absence of pupillary response 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.

Which of the following terms refers to the inability to coordinate muscle movements, resulting difficulty walking?

Ataxia Ataxia is the inability to coordinate muscle movements, resulting in difficulty walking. 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.

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?

Occipital The occipital lobe is responsible for interpreting visual stimuli. The frontal lobe influences personality, judgment, abstract reasoning, social behavior, language expression, and movement. The temporal lobe controls hearing, language comprehension, and storage and memory recall (although memory recall is also stored throughout the brain). The parietal lobe interprets and integrates sensations, including pain, temperature, and touch; it also interprets size, shape, distance, and texture.

A nurse is completing a neurological assessment and determines that the client has significant visual deficits. A brain tumor is considered. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit?

Occipital The vision center is located in the occipital lobe. There is little other functioning that may interfere with the visual process in the other lobes of the brain.

The nurse is completing a neurologic assessment and uses the whisper test to assess which of the following cranial nerves?

Acoustic Clinical examination of the acoustic nerve can be done by the whisper test. Having the patient say "ah" tests the vagus nerve. Observing for symmetry when the patient performs facial movements tests the facial nerve. The olfactory nerve is tested by having the patient identify specific odors.

Which of the following terms refers to the inability to coordinate muscle movements, resulting in difficulty walking?

Ataxia Ataxia is the inability to coordinate muscle movements, resulting in difficulty walking. 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.

Which of the following terms is used to describe the fibrous connective tissue that covers the brain and spinal cord?

Meninges The meninges have three layers, the dura mater, arachnoid mater, and pia mater. The dura mater is the outmost layer of the protective covering of the brain and spinal cord. The arachnoid is the middle membrane of the protective covering of the brain and spinal cord. The pia mater is the innermost membrane of the protective covering of the brain and spinal cord.

Which cranial nerve is tested by listening to a ticking watch?

Acoustic The acoustic nerve (VIII) assesses hearing by rubbing the fingers, placing a ticking watch, or whispering near each ear. The facial nerve (VII) is assessed for symmetry of facial movement. The trigeminal nerve (V) is assessed for facial sensation, corneal reflex, and chewing or mastication. The vagus nerve (X) is assessed by swallowing and gag reflex.

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?

Inform the client that he will not experience any electrical shock. 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.

A patient is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in which of the following?

Thought content Hallucinations are a disturbance of thought content. They are not disturbances in motor ability, intellectual function, or emotional status.

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?

"Although the required position may not be comfortable, it will make the procedure safer and easier to perform." 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.

A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following?

"The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid." Loss of CSF causes the headache. Occasionally, if the headache persists, the epidural blood patch technique may be used. Blood is withdrawn from the antecubital vein and injected into the site of the previous puncture. The rationale is that the blood will act as a plug to seal the hole in the dura and preven further loss of CSF. The blood is not put into the subarachnoid space. The needle is inserted below the level of the spinal cord, which prevents damage to the cord. It is not a lack of moisture that prevents healing; it is more related to the size of the needle used for the puncture.

A patient is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the patient has?

Dysfunction of the vagus nerve The vagus nerve (cranial nerve X) controls the gag reflex and is tested by depressing the posterior tongue with a tongue blade. An absent gag reflex is a significant finding, indicating dysfunction of this nerve.

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 cranial nerve:

VIII 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.

Which of the following are sympathetic effects of the nervous system?

Dilated pupils Dilated pupils are a sympathetic effect of the nervous system. Constricted pupils are a parasympathetic effect. Decreased blood pressure is a parasympathetic effect. Increased blood pressure is a sympathetic effect. Increased peristalsis is a parasympathetic effect. Decreased peristalsis is a sympathetic effect. Decreased respiratory rate is a parasympathetic effect. Increased respiratory rate is a sympathetic effect.

Which of the following cerebral lobes is the largest and controls abstract thought?

Frontal The frontal lobe also controls information storage or memory and motor function. The temporal lobe contains the auditory receptive area. 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.

Which of the following cerebral lobes contains the auditory receptive areas?

Temporal 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.

A nurse is working in a neurologist's office. The physician orders a Romberg test. The nurse should have the client:

close his or her eyes and stand erect. 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.

A male patient is scheduled for an EEG. The patient inquires about any diet-related prerequisites that he must take. Which of the following diet-related advice should the nurse provide to the patient?

Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours prior to the test The patient is advised to refrain from taking sedative drugs or drinks that contain caffeine for at least 8 hours prior to the test because these may interfere with the EEG test result. The patient is not advised to increase or decrease the intake of minerals in the diet.

A female patient has undergone a lumbar puncture for a neurological assessment. The patient is put under the postprocedure care of a nurse. Which of the following important postprocedure nursing interventions should be performed to ensure maximum comfort to the patient?

Encourage a liberal fluid intake for the patient The nurse should encourage the patient to take liberal fluids and inspect the injection site for swelling or hematoma. These measures help restore the volume of CSF extracted. The patient is administered antihistamines before a test only if he or she is allergic to contrast dye and contrast dye will be used. The room of the patient who has undergone a lumbar puncture should be kept dark and quiet. The patient should be encouraged to rest, because sensory stimulation tends to magnify discomfort.

A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate?

Flaccidity The nurse would document flaccidity when the client makes no motor response to stimuli. Abnormal posturing and weak motor tone would be documented specifically as the nurse would assess. Decorticate posturing is when a client is stiff with bent arms and clenched fists with legs straight out.

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?

Lateral recumbent, with chin resting on flexed knees To maximize the space between the vertebrae, the client is placed in a lateral recumbent position with knees flexed toward the chin. The needle is inserted between L4 and L5. The other positions wouldn't allow as much space between L4 and L5.

Which neurons transmit impulses from the CNS?

Motor Neurons are either sensory or motor. Sensory neurons transmit impulses to the CNS; motor neurons transmit impulses from the CNS. A membranous sheath called the neurilemma covers the myelin of axons in peripheral nerves. Dendrites are threadlike projections or fibers.

A client who has sustained a head injury to the parietal lobe cannot identify a familiar object by touch. The nurse knows that this deficit is which of the following?

Tactile agnosia Tactile agnosia is the inability to identify a familiar object by touch. Visual agnosia is the loss of ability to recognize objects through sight. The Romberg test has to do with balance. Ataxia is defined as incoordination of voluntary muscle action.

The nurse is performing a neurological assessment of a client who has sustained damage to the frontal cortex. Which of the following deficits will the nurse look for during assessment?

The inability to tell how a mouse and a cat are alike The client with damage to the fronal cortex will display a deficit in intellectual functioning. Questions designed to assess this capacity might include the ability to recognize similarities: for example, how are a mouse and dog or pen and pencil alike? The Romberg test assesses balance, which has to do with the cerebellar and basal ganglia influence on the motor system. Absence of movement below the waist suggests a deficit with the spinal cord. Intentional tremors have to do with deficits of the motor system

A patient is scheduled for standard EEG testing to evaluate a possible seizure disorder. Nursing interventions prior to the procedure include which of the following?

Withholding antiseizure medications for 24 to 48 hours prior to the exam Antiseizure 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 patient 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, the meal is not omitted, because an altered blood glucose level can cause changes in brain wave patterns. The patient is informed that the standard EEG takes 45 to 60 minutes; a sleep EEG requires 12 hours.

Which diagnostic procedure would the nurse anticipate first if the goal was to obtain a thin slice of a muscular body area?

computed tomography (CT) A computer tomography scan uses x-rays and computer analysis to produce three-dimensional views of the slices of the body. This is a good first test to obtain information. 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.

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, the nurse anticipates that the liver will

convert glycogen to glucose for immediate use. 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.

During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to:

support the joint where the tendon is being tested 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.

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:

sympathetic nervous system. 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.

The nurse is assessing the mental status of a patient. Which of the following questions will the nurse include in the assessment?

"Who is the president of the United States?" Assessing orientation to time, place, and person assists in evaluating mental status. Does the patient know what day it is, what year it is, and the name of the president of the United States? Is the patient aware of where he or she is? Is the patient aware of who the examiner is and of his or her purpose for being 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 patient's intellectual function. "Are you having hallucinations?" assesses the patient's thought content.

A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test?

Determine whether the client is allergic to iodine, contrast dyes, or shellfish. Because CT commonly involves use of a contrast agent, the nurse should determine whether the client is allergic to iodine, contrast dyes, or shellfish. Neck immobilization is necessary only if the client has a suspected spinal cord injury. Placing a cap over the client's head may lead to misinterpretation of test results; instead, the hair should be combed smoothly. The physician orders a sedative only if the client can't be expected to remain still during the CT scan.

A client has sustained a head injury to the occipital area. He cannot identify a familiar object by looking at it. The nurse knows that this deficit is which of the following?

Visual agnosia Visual agnosia is the loss of ability to recognize objects when seeing them. The Romberg test has to do with balance. Ataxia is defined as incoordination of voluntary muscle action. Astereognosis is the inability to identify an object by touch.

A client is admitted to an acute care facility for treatment of a brain tumor. When reviewing the chart, the nurse notes that the client's extremity muscle strength is rated 1/5. Which assessment finding should the nurse anticipate? Muscle contraction or movement is undetectable. Normal, full muscle strength is present. Muscles move actively against gravity alone. Muscle contraction is palpable and visible.

Muscle contraction is palpable and visible. Muscle strength is assessed and rated on a five-point scale in all four extremities, comparing one side to the other. Palpable, visible muscle contraction on the affected side and normal, full muscle strength on the unaffected side indicate a rating of 1/5. Normal, full muscle strength on both sides is rated 5/5. Active muscle movement against gravity alone on the affected side with normal, full muscle strength on the unaffected side is rated 3/5. Undetectable muscle contraction or movement on the affected side with normal, full muscle strength on the unaffected side is rated 0/5.

Which neurotransmitter demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways?

Serotonin The sources of serotonin are the brain stem, hypothalamus, and dorsal horn of the spinal cord. Enkephalin is excitatory and associated with pleasurable sensations. Norepinephrine is usually excitatory and affects mood and overall activity. Acetylcholine is usually excitatory, but the parasympathetic effects are sometimes inhibitory.

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. 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.