neuro assessment questions
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? a) 3+ b) 1+ c) 0 d) 2+
1+ Correct 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+.
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 slowing transmission of the motor neurons, which deficits are anticipated? a) A delayed reaction in processing the information transferred from the environment b) A delayed reaction in cognitive ability to understand the relayed information c) A delayed reaction in response due to the interrupted impulses from the central nervous system d) A delayed reaction in identification of information due to slowed passages of information to brain
A delayed reaction in response due to the 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. A deficit in 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
The nurse is assisting with a lumbar puncture and observes that when the physician obtains CSF, it is clear and colorless. What does this finding indicate? a) Local trauma from the insertion of the needle b) A subarachnoid hemorrhage c) An overwhelming infection d) A normal finding; the fluid will be sent for testing to determine other factors
A normal finding; the fluid will be sent for testing to determine other factors Correct Explanation: The CSF should be clear and colorless. Pink, blood-tinged, or grossly bloody CSF may indicate a subarachnoid hemorrhage. The CSF may be bloody initially because of local trauma but becomes clearer as more fluid is drained. Specimens are obtained for cell count, culture, glucose, protein, and other tests as indicated. The specimens should be sent to the laboratory immediately because changes will take place and alter the result if the specimens are allowed to stand. (less)
The nurse is completing a neurologic assessment and uses the whisper test to assess which of the following cranial nerves? a) Facial b) Vagus c) Acoustic d) Olfactory
Acoustic Correct Explanation: 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.
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? a) "There's no other option but to assume the knee-chest position." b) "I'll report your concerns to the physician." c) "Although the required position may not be comfortable, it will make the procedure safer and easier to perform." d) "Lying on your left side will be fine during the procedure."
Although the required position may not be comfortable, it will make the procedure safer and easier to perform." Correct 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.
A patient is scheduled for an electroencephalogram (EEG) in the morning. What food on the patient's tray should the nurse remove prior to the test? a) Coffee b) Eggs c) Orange juice d) Toast
Coffee Correct Explanation: Antiseizure agents, tranquilizers, stimulants, and depressants should be withheld 24 to 48 hours before an EEG, because these medications can alter the EEG wave patterns or mask the abnormal wave patterns of seizure disorders (Pagana & Pagana, 2009). Coffee, tea, chocolate, and cola drinks are omitted from the meal before the test because of their stimulating effect. However, the meal itself is not omitted, because an altered blood glucose level can cause changes in brain wave patterns.
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? a) Dysfunction of the acoustic nerve b) Dysfunction of the spinal accessory nerve c) Dysfunction of the vagus nerve d) Dysfunction of the facial nerve
Dysfunction of the vagus nerve Explanation: 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. (less)
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? a) Encourage a liberal fluid intake for the patient b) Help the patient take a brisk walk around the testing area c) Keep the room brightly lit and play soothing music in the background d) Administer antihistamines according to the physician's prescription
Encourage a liberal fluid intake for the patient Correct Explanation: 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. (less)
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? a) Decorticate posturing b) Abnormal posture c) Flaccidity d) Weak muscular tone
Flaccidity Correct Explanation: 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
Which lobe of the brain is responsible for concentration and abstract thought? a) Frontal b) Temporal c) Parietal d) Occipital
Frontal Correct Explanation: 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.
Cranial nerve IX is also known as which of the following? a) Hypoglossal b) Vagus c) Spinal accessory d) Glossopharyngeal
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.
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? a) "I am trying to quit smoking and have a patch on." b) "I have been trying to get an appointment for so long." c) "My legs go numb sometimes when I sit too long." d) "I have not had anything to eat or drink since 3 hours ago."
I am trying to quit smoking and have a patch on." Correct 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). (less)
Which of the following terms is used to describe the fibrous connective tissue that covers the brain and spinal cord? a) Meninges b) Arachnoid mater c) Pia mater d) Dura mate
Meninges Explanation: 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.
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? a) Occipital b) Frontal c) Temporal d) Parietal
Occipital Correct Explanation: 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 patient has difficulty interpreting his awareness of body position in space. Which lobe is most likely to be damaged? a) Temporal b) Occipital c) Frontal d) Parietal
Parietal Correct Explanation: The parietal lobe is the primary sensory cortex. It is essential to a person's awareness of his body in space, as well as orientation in space and spatial relations.
The Family Nurse Practitioner is assessing a 55-year-old who came to the clinic complaining of being "unsteady" on their feet. What would be a test for equilibrium? a) Walking and turning abruptly b) Romberg test c) Carlsburg test d) Heel-to-toe test
Romberg test Correct Explanation: In the Romberg test, the client stands with feet close together and eyes closed. If the client sways and tends to fall, this is considered a positive Romberg test, indicating a problem with equilibrium. The examiner stands fairly close to the client during this test in case the client loses balance
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? a) Absence of movement below the waist b) The inability to tell how a mouse and a cat are alike c) The inability to maintain steady balance for the Romberg test d) Intentional tremors
The inability to tell how a mouse and a cat are alike Correct Explanation: 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
What part of the brain controls and coordinates muscle movement? a) Cerebellum b) Cerebrum c) Midbrain d) Brain stem
cerebellum
A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates: a) dysfunction in the spinal column. b) dysfunction in the cerebrum. c) risk for increased intracranial pressure. d) dysfunction in the brain stem.
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.
During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to: a) tap the tendon slowly and softly. b) support the joint where the tendon is being tested. c) use the pointed end of the reflex hammer when striking the Achilles tendon. d) hold the reflex hammer tightly.
support the joint where the tendon is being tested. Correct 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. (