Neuro Fx PrepU

The trochlear nerve controls which function?

Eye muscle movement

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. Rationale: The nurse should support the joint where the tendon is being tested to prevent the attached muscle from contracting.

When learning about the nervous system, students learn that which nervous system regulates the expenditure of energy?

Sympathetic Rationale: This division of the autonomic nervous system regulates the expenditure of energy.

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 Rationale: 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.

A critical care nurse is documenting her assessment of a client she is caring for. The client is status post-resection of a brain tumor. The nurse documents that the client is flaccid on the left. What does this mean?

The client is not responding to stimuli Rationale: Flaccidity is when the client makes no motor response to stimuli. Flaccidity is a motor assessment.

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 Rationale: The client with damage to the frontal 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 brain stem holds the medulla oblongata. What is the function of the medulla oblongata?

Transmits motor impulses from the brain to the spinal cord Rationale: The medulla oblongata lies below the pons and transmits motor impulses from the brain to the spinal cord and sensory impulses from peripheral sensory neurons to the brain. The medulla contains vital centers concerned with respiration, heartbeat, and vasomotor activity (the control of smooth muscle activity in blood vessel walls).

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?

X Rationale: 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.

A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in

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

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

"Do you have any problems with balance?" Rationale: To evaluate cerebellar function, the nurse should ask the client about problems with balance and coordination.

The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern?

Cerebrospinal fluid is cloudy in nature. Rationale: The nurse would note cloudy cerebrospinal fluid as a concern. Cloudy fluid is an indication of infection.

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

Frontal Rationale: 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.

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 Rationale: 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

Which term describes the fibrous connective tissues that cover the brain and spinal cord?

Meninges Rationale: 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.

A patient has difficulty interpreting his awareness of body position in space. Which lobe is most likely to be damaged?

Parietal Rationale: 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.

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." Rationale: 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

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." Rationale: 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 spinal cord is composed of 31 pairs of spinal nerves. How many pairs of thoracic nerves are contained within the spinal column?

12 Rationale: There are twelve pairs of thoracic nerves, five lumbar and sacral nerves, eight cervical, and one coccygeal.

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 normal finding; the fluid will be sent for testing to determine other factors Rationale: 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.

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, the nurse would anticipate a delayed reaction in:

A response due to interrupted impulses from the central nervous system Rationale: 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.

Which of the following neurotransmitters are deficient in myasthenia gravis?

Acetylcholine Rationale: A decrease in the amount of acetylcholine causes myasthenia gravis. A decrease of serotonin leads to depression. Parkinson's disease is caused by a depletion of dopamine. Decreased levels of GABA may cause seizures.

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

Acoustic Rationale: The acoustic nerve (VIII) assesses hearing by rubbing the fingers, placing a ticking watch, or whispering near each ear.

A client undergoes a scheduled electroencephalogram (EEG). Which of the following post-procedure activities should the nurse carry out for the client?

Allow the client to rest and shampoo the client's hair. Rationale: After an EEG, the nurse should ensure rest for the sleep-deprived client and shampoo the client's hair to remove the glue used to affix electrodes to the scalp.

A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first?

Assess the client for medication allergies. Rationale: 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 shellfish, 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.

Which term refers to the inability to coordinate muscle movements, resulting in difficulty walking?

Ataxia

What part of the brain controls and coordinates muscle movement?

Cerebellum Rationale: The cerebellum, which is located behind and below the cerebrum, controls and coordinates muscle movement.

Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed?

Clonus Rationale: 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.

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. Rationale: 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.

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?

Decrease in heart rate Rationale: 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.

Which term refers to a method of recording, in graphic form, the electrical activity of a muscle?

Electromyography Rationale: An electromyogram is obtained by inserting needle electrodes into the skeletal muscles to measure changes in the electrical potential of the muscles.

Lower motor neuron lesions cause

Flaccid muscles Rationale: 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.

Which cerebral lobes is the largest and controls abstract thought?

Frontal Rationale: 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.

To assess a client's cranial nerve function, a nurse should assess:

Gag reflex Rationale: The gag reflex is governed by the glossopharyngeal nerve, one of the cranial nerves. Hand grip and arm drifting are part of motor function assessment. Orientation is an assessment parameter related to a mental status examination.

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 Rationale: 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

Which of the following areas of the brain are responsible for temperature regulation?

Hypothalamus Rationale: The hypothalamus also controls and regulates the autonomic nervous system and maintains temperature by promoting vasoconstriction or vasodilation.

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 Rationale: 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.

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 and chin toward the chest Rationale: 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.

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?

Parasympathetic Rationale: 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.

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.

Pinpoint pupils Unequal pupils Absence of pupillary response Rationale: 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.

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?

Romberg Rationale: 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.

Which cerebral lobe contains the auditory receptive areas?

Temporal Rationale: 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 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:

Turning the client's head suddenly while holding the eyelids open. Rationale: 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 provider orders the Romberg test for a patient. The nurse tells the patient that the provider wants to evaluate his equilibrium by assessing which cranial nerve?

VIII Rationale: Cranial nerve VIII (acoustic) can be checked to assess equilibrium status.

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 Rationale: There are 12 pairs of cranial nerves. Cranial nerve VIII is the vestibulocochlear or auditory nerve responsible for hearing and balance.

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

Depression Rationale: 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.

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 Rationale: Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing, and coughing. Therefore, the nurse should monitor the client closely for hypoxia.

A patient is admitted to a specialty care unit with a diagnosis of an upper motor neuron lesion. The nurse assesses the patient and documents the presence of:

Muscle spacsity Rationale: An upper motor neuron lesion is associated with increased muscle tone, muscle spasticity, no muscle atrophy, and hyperactive and abnormal reflexes. Refer to Table 43-4 in the text.

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." Rationale: 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 prevent 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.

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?" Rationale: 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.

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 Rationale: Cranial nerve I, the olfactory nerve, allows sense of smell.

The nurse is assessing the pupils of a patient who has had a head injury. What does the nurse recognize as a parasympathetic effect?

Constricted pupils Rationale: Constricted pupils are a parasympathetic effect; dilated pupils are a sympathetic effect.

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. Rationale: 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.

Age-related changes in the neurologic system must be carefully assessed. Which of the following changes does the nurse expect to find in some degree depending on the patient's age and medical condition? Select all that apply.

Decreased muscle mass Reduced papillary responses Increased sensitivity to heat and cold Refer to Table 43-5 in the text.

Which is a sympathetic effect of the nervous system?

Dilated pupils Rationale: Dilated pupils, increased blood pressure, decreased peristalsis, and increased respiratory rate are sympathetic effects of the nervous system.

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 brain stem Rationale: 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 has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important post-procedure nursing intervention should be performed to ensure the client's maximum comfort?

Encourage the client to drink liberal amounts of fluids Rationale: The nurse should encourage the client to take liberal fluids and should inspect the injection site for swelling or hematoma. These measures help restore the volume of cerebrospinal fluid extracted.

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 Rationale: 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.

The nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response?

Observing the client's response to painful stimulus Rationale: The nurse evaluates motor response in a comatose or unconscious client by administering a painful stimulus. This action helps determine if the client makes an appropriate response by reaching toward or withdrawing from the stimulus.

The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart?

CN II Rationale: The nurse assesses vision and thus the optic nerve (cranial nerve II) by use of a Snellen eye chart.

There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected with decreased visual fields.

CN II Rationale: The three sensory cranial nerves are I, II and VIII. Cranial nerve II (optic) is affected with decreased visual fields and acuity.

Cranial nerve IX is also known as which of the following?

Glossopharyngeal

Lesions in the temporal lobe may result in which type of agnosia?

Auditory Rationale: 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.

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 Rationale: 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.

A 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 Rationale: The nurse would anticipate a cerebral angiography, which detects distortion of the cerebral arteries and veins

A patient had a lumbar puncture 3 days ago in the outpatient clinic and calls the nurse with complaints of a throbbing headache. What can the nurse educate the patient to do for relief of the discomfort? Select all that apply.

Force fluids (unless contraindicated) Get plenty of bed rest Take some over the counter analgesics Rationale: A post-puncture headache is usually managed by bed rest, analgesic agents, and hydration.

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?

+1 Rationale: 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+.

The critical care nurse is giving end-of-shift report on a client she is caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate?

Comatose Rationale: The GSC is used to measure the LOC. The scale consists of three parts: eye opening response, best verbal response, and best motor response. A normal response is 15. A score of 7 or less is considered comatose. Therefore, a score of 6 indicates the client is in a state of coma and not in any other state such as stupor or somnolence. The evaluations are recorded on a graphic sheet where connecting lines show an increase or decrease in the LOC.

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?

Helicopod Rationale: 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.

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 Rationale: 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 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 Rationale: 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.

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 Rationale: 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.

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. Rationale: 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.

Which cranial nerve is responsible for muscles that move the eye and lids?

Oculomotor Rationale: The oculomotor, cranial nerve III, is responsible for movement of the eye and lids, pupillary constriction and lens accommodation.

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?

V Rationale: 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.

Which safety action will the nurse implement for a client receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)?

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

Which term refers to the inability to recognize objects through a particular sensory system?

Agnosia Rationale: Agnosia may be visual, auditory, or tactile.

A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture?

Position the client flat for at least 3 hours. Rationale: A client who has undergone a lumbar puncture should be positioned flat for at least 3 hours and given adequate fluids. These measures help restore the cerebrospinal fluid volume extracted from the client and are priority activities.

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 right now Rationale: 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.

A nurse is performing a neurologic assessment on a client. The nurse observes the client's tongue for symmetry, tremors, and strength, and assesses the client's speech. Which cranial nerve is the nurse assessing?

XII Rationale: Cranial nerve XII, the hypoglossal nerve, controls tongue movements involved in swallowing and speech. The tongue should be midline, symmetrical, and free from tremors and fasciculations. The nurse tests tongue strength by asking the client to push his tongue against his cheek as the nurse applies resistance. To test the client's speech, the nurse may ask him to repeat the sentence, "Round the rugged rock that ragged rascal ran."

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. Rationale: 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.