PrepU: Chapter 65: Assessment of Neurologic Function
A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction? "Don't eat anything for 12 hours before the test." "Avoid stimulants and alcohol for 24 to 48 hours before the test." "Don't shampoo your hair for 24 hours before the test." "Avoid thinking about personal matters for 12 hours before the test."
"Avoid stimulants and alcohol for 24 to 48 hours before the test." Explanation: For 24 to 48 hours before an EEG, the client should avoid coffee, cola, tea, alcohol, and cigarettes because these may interfere with the accuracy of test results. (For the same reason, the client also should avoid antidepressants, sedatives, and anticonvulsants.) To avoid a reduced serum glucose level, which may alter test results, the client should eat normal meals before the test. The hair should be washed before an EEG because the electrodes must be applied to a clean scalp. The client's thoughts don't affect the test results.
To evaluate a client's cerebellar function, a nurse should ask: "Have you noticed any changes in your muscle strength?" "Do you have any trouble swallowing food or fluids?" "Do you have any problems with balance?" "Do you have any difficulty speaking?"
"Do you have any problems with balance?" Explanation: 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.
A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first? Obtain two large-bore IV lines. Obtain a blood sample to evaluate BUN and creatinine concentrations. Maintain the client NPO for 6 hours before the test. Assess the client for medication allergies.
Assess the client for medication allergies. Explanation: 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 iodine, 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? Spasticity Rigidity Agnosia Ataxia
Ataxia Explanation: Ataxia is the inability to coordinate voluntary muscle action; tremors (rhythmic, involuntary movements) noted at rest or during movement suggest a problem in the anatomic areas responsible for balance and coordination. 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.
Lesions in the temporal lobe may result in which type of agnosia? Auditory Relationship Tactile Visual
Auditory Explanation: 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.
Lesions in the temporal lobe may result in which type of agnosia? Visual Relationship Tactile Auditory
Auditory Explanation: 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.
What part of the brain controls and coordinates muscle movement? Cerebellum Cerebrum Midbrain Brain stem
Cerebellum Explanation: The cerebellum, which is located behind and below the cerebrum, controls and coordinates muscle movement.
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? Myelogram Cerebral angiography Echoencephalography Electroencephalogram
Cerebral angiography Explanation: 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.
The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve? Cranial nerve XII Cranial nerve XI Cranial nerve I Cranial nerve V
Cranial nerve XII Explanation: Assessment of the movement of the tongue is cranial nerve XII . Cranial nerve I is the olfactory nerve. Cranial nerve V is the trigeminal nerve responsible for sensation to the face and chewing. Cranial nerve XI is the spinal or accessory nerve responsible for head and shoulder and shoulder movement.
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. Stage IV sleep is prolonged Increased sensitivity to heat and cold Reduced papillary responses Hyper-reactive deep tendon reflexes Decreased muscle mass
Decreased muscle mass Increased sensitivity to heat and cold Reduced papillary responses
Low levels of the neurotransmitter serotonin lead to which of the following disease processes? Depression Seizures Parkinson's disease Myasthenia gravis
Depression Explanation: 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 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 acoustic nerve Dysfunction of the spinal accessory nerve Dysfunction of the facial nerve Dysfunction of the vagus 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.
Which term refers to a method of recording, in graphic form, the electrical activity of a muscle? Electromyography Electroencephalography Electrogastrography Electrocardiography
Electromyography Explanation: An electromyogram is obtained by inserting needle electrodes into the skeletal muscles to measure changes in the electrical potential of the muscles. Electroencephalography 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.
Note that no special safety actions need to be taken Check the client's oxygen saturation level using a pulse oximeter after the client has been placed on the MRI table Securely fasten the client's portable oxygen tank to the bottom of the MRI table after the client has been positioned on the top of the MRI table Ensure that no client care equipment containing metal enters the room where the MRI is located.
Ensure that no client care equipment containing metal enters the room where the MRI is located. Explanation: For client safety the nurse must make sure no client care equipment that contains metal or metal parts (e.g., portable oxygen tanks) enters the room where the MRI is located. 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.
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? Decorticate posturing Flaccidity Weak muscular tone Abnormal posture
Flaccidity 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? Temporal Frontal Parietal Occipital
Frontal 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.
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 Parietal lobe Occipital lobe Temporal lobe
Frontal lobe Explanation: 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 (Hickey, 2009).
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 experience only mild electrical shock. Encourage adequate water intake by the client. Inform the client that he will not experience any electrical shock. Distract the client's attention from the test.
Inform the client that he will not experience any electrical shock. Explanation: 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 client presents to the emergency department status post-seizure. The physician wants to know what the pressure is in the client's head. What test might be ordered on this client? Echoencephalography Nerve conduction studies EMG Lumbar puncture
Lumbar puncture Explanation: Changes in CSF occur in many neurologic disorders. A lumbar puncture (spinal tap) is performed to obtain samples of CSF from the subarachnoid space for laboratory examination and to measure CSF pressure.
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? Temporal Parietal Occipital Frontal
Occipital 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.
Which cranial nerve is responsible for muscles that move the eye and lids? Vestibulocochlear Trigeminal Oculomotor Facial
Oculomotor Explanation: 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 (VIII) cranial nerve is responsible for hearing and equilibrium. The facial (VII) nerve is responsible for salivation, tearing, taste, and sensation in the ear.
A geriatric nurse practitioner is assessing older adults. The nurse practitioner knows that older adults sometimes have difficulty following directions during a neurologic examination or diagnostic procedure. What strategies can the nurse practitioner use to examine older clients? Provide brief instructions, one step at a time Suggest a nurse or an examiner who is of their age Offer incentives such as sweets Spread the examination over 2 or 3 days
Provide brief instructions, one step at a time Explanation: Older adults who have difficulty following directions during a neurologic examination or diagnostic procedure need brief instructions given one step at a time during the examination or procedure. In addition, diseases that are more common in older adults, such as dementia, often make it difficult to perform a neurologic assessment. The nurse should not offer incentives to them. In addition, spreading the examination over a couple of days or suggesting an examiner of their age may not help in examining older adults.
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? Walking and turning abruptly Heel-to-toe test Carlsberg test Romberg test
Romberg test 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.
Which neurotransmitter demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways? Enkephalin Serotonin Norepinephrine Acetylcholine
Serotonin Explanation: The brain stem, hypothalamus, and dorsal horn of the spinal cord are sources of serotonin. 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.
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: Balance. Vision. Hearing. Speech.
Speech. Explanation: 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 spinal cord is composed of 31 pairs of spinal nerves. How many pairs of thoracic nerves are contained within the spinal column? Eight Twelve One Five
Twelve Explanation: There are twelve pairs of thoracic nerves, five lumbar and sacral nerves, eight cervical, and one coccygeal.
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? VII X VIII III
VIII Explanation: Cranial nerve VIII (acoustic) can be checked to assess equilibrium status.
Lower motor neuron lesions cause no muscle atrophy. increased muscle tone. flaccid muscles. hyperactive and abnormal reflexes.
flaccid muscles. Explanation: 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.
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: gait alteration. visual disturbance. fever. hypoxia.
hypoxia. Explanation: Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing, and coughing. Therefore, the nurse should monitor the client closely for hypoxia. Temperature control, vision, and gait aren't lower brain stem functions.
A nurse is noting from a client's neurologic assessment findings that the client's motor impulses are interrupted from the brain to the spinal cord. It also appears that the client lacks sensory impulses from the peripheral sensory neurons to the brain. Which area has the deficit? midbrain subarachnoid space pons medulla oblongata
medulla oblongata Explanation: The medulla oblongata lies below the pons and transmits motor impulses from the brain to the spinal cord, and sensory impulses from the peripheral sensory neurons to the brain. The pons is part of the brainstem. The midbrain forms the forward part of the brainstem and connects the pons and the cerebellum with the two cerebral hemispheres. The subarachnoid space lies between the pie matter and the arachnoids membrane.
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 wear any hearing aids while in the hospital. use the walker when walking. have their spouse bring in the client's glasses. refrain from eating or drinking for now.
refrain from eating or drinking for now. Explanation: 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. The other instructions are associated with abnormalities of CN II (optic) and CN VIII (acoustic).
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: processing information transferred from the environment. response due to interrupted impulses from the central nervous system identification of information due to slowed passages of information to brain. cognitive ability to understand relayed information.
response due to 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. 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 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: musculoskeletal system. sympathetic nervous system. endocrine system. parasympathetic nervous system.
sympathetic nervous system. Explanation: 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.
A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in motor ability. thought content. emotional status. intellectual function.
thought content. Explanation: Hallucinations are disturbances of thought content. They are not disturbances in motor ability, intellectual function, or emotional status.
