Test 2 - Neuro 1 - Hart
A nurse is evaluating a client's cranial nerves during a routine examination. To assess the function of cranial nerve XII (hypoglossal), the nurse should assess the client's ability to: a. elevate the shoulders, both with and without resistance. b. smell and identify a nonirritating, aromatic odor. c. stick out the tongue and move it rapidly from side to side and in and out. d. read an eye chart from a distance of 20?.
c. stick out the tongue and move it rapidly from side to side and in and out. To test cranial nerve XII, which controls tongue movement, the nurse should instruct the client to stick out the tongue and move it rapidly from side to side and in and out. The nurse would ask the client to smell and identify a nonirritating, aromatic odor when testing the function of cranial nerve I, the olfactory cranial nerve. Asking the client to read an eye chart is part of assessing cranial nerve II, the optic cranial nerve. Having the client elevate the shoulders with and without resistance is part of assessing cranial nerve XI, the spinal accessory cranial nerve that innervates the sternocleidomastoid muscle and the upper portion of the trapezius muscle. Ch. 60: Assessment of Neurologic Function - Page 1972
A potential complication of a hemorrhagic stroke is interference with the ability of the arachnoid villi to absorb CSF. Therefore, fluid in the ventricles increase beyond the amount that is usually absorbed daily, which is: a. 350 to 375 mL. b. 275 to 325 mL. c. 150 to 200 mL. d. 200 to 250 mL.
a. 350 to 375 mL. In the normal adult, approximately 500 mL of CSF is produced each day; all but 125 to 150 mL is absorbed by the villi (Hickey, 2009). When blood enters the system (from trauma or hemorrhagic stroke), the villi become obstructed, CSF is not absorbed, and hydrocephalus (increased size of ventricles) may result. Ch. 60: Assessment of Neurologic Function - Page 1970
The nurse is caring for a client with bacterial meningitis. Which assessment finding(s) is most important in determining nursing care for a client with bacterial meningitis? Select all that apply. a. Cloudy cerebral spinal fluid b. Low red blood cell (RBC) count c. Purpura of hands and feet d. Pain and stiffness of the extremities e. Low white blood cell (WBC) count f. Low antidiuretic hormone (ADH) levels
a. Cloudy cerebral spinal fluid c. Purpura of hands and feet The cerebral spinal fluid (CSF) will be cloudy if bacterial meningitis is the causative agent. Purpura indicates a serious complication of bacterial meningitis (disseminated intravascular coagulation) is occurring and may place the client at risk for amputation of those parts. Pain and stiffness of the extremities is not indicative of meningitis. A rise in RBCs, WBCs, and ADH would be expected. Ch. 61: Management of Patients with Neurologic Dysfunction
The nurse is expecting to admit a client with a diagnosis of meningitis. While preparing the client's room, which of the following would the nurse most likely have available? a. Equipment to maintain infection control precautions b. IV tensilon c. Extra lighting d. Nasogastric tubing
a. Equipment to maintain infection control precautions An important component of nursing care for the client with meningitis is instituting infection control precautions until 24 hours after initiation of antibiotic therapy. Oral and nasal discharge is considered infectious. This client may well experience photophobia, so the lighting should be kept dim. IV Tensilon is used to diagnose myasthenia gravis. Ch. 64: Management of Patients with Neurologic Infections, Autoimmune Disorders, and Neuropathies - Page 2090
The nurse is caring for a client with a traumatic brain injury and experiencing increased intracranial pressure. The nurse has administered mannitol, an osmotic diuretic, as ordered. This medication promotes the shift of fluid from the intracellular to the intravascular compartment. Therefore, it is necessary for the nurse to continually assess for which of the following? a. Heart failure b. Kidney failure c. Diabetes insipidus d. Pancreatitis
a. Heart failure It is possible for the client to have a fluid overload that creates such an increased workload for the heart that it fails. Ch. 61: Management of Patients with Neurologic Dysfunction - Page 2005
A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include thickened liquids. Which of the following is the priority nursing diagnosis for this client? a. Impaired Swallowing b. Malnutrition Risk c. Decreased Fluid Volume Risk d. Aspiration Risk
a. Impaired Swallowing Impaired Swallowing was evident on the video fluoroscopy. Aspiration, Malnutrition, and Decreased Fluid Volume Risk can occur but are not the primary diagnosis at this point in time. Ch. 62: Management of Patients with Cerebrovascular Disorders - Page 2041
A client diagnosed with acute kidney injury (AKI) has developed congestive heart failure. The client has received 40 mg of intravenous push (IVP) Lasix and 2 hours later, the nurse notes that there are 50 mL of urine in the Foley catheter bag. The client's vital signs are stable. Which health care order should the nurse anticipate? a. Lasix 80 mg IVP b. Mannitol 12.5 g IVP c. Chest x-ray d. Normal saline bolus of 500 mL
a. Lasix 80 mg IVP Diuretic agents are often used to control fluid volume in clients with acute kidney injury (AKI). The client's urine output indicates an inadequate response to the initial dosage of Lasix and the nurse should anticipate administering Lasix 80 mg IVP. Often in this situation, the initial dosage of Lasix is doubled. The client is experiencing fluid overload, thus, a 500-mL bolus of normal saline bolus would be contraindicated. There is no need to complete a chest x-ray. Mannitol is widely used in the management of cerebral edema and increased intracranial pressure from multiple causes. Ch. 48: Management of Patients with Kidney Disorders - Page 1565
A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure? a. Lethargy b. Blood pressure 100/60 mm Hg c. Periorbital edema d. Nausea
a. Lethargy Decreasing level of consciousness is one of the earliest signs of increased intracranial pressure (ICP). Without a baseline for the blood pressure, it is difficult to determine whether this is a significant change for this client. Vomiting (usually without forewarning of nausea) when associated with a head injury suggests increasing ICP. Periorbital edema is more suggestive of fluid overload than ICP. Ch. 61: Management of Patients with Neurologic Dysfunction - Page 2009
After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question? a. Performing a lumbar puncture b. Elevating the head of his bed c. Placing him on mechanical ventilation d. Giving him a barbiturate
a. Performing a lumbar puncture The client's history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn't be done because it can quickly decompress the central nervous system, causing additional damage. After a head injury, barbiturates may be given to prevent seizures; mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce ICP. Ch. 61: Management of Patients with Neurologic Dysfunction - Page 2001
A client with a history of a brain tumor is undergoing diagnostic testing to evaluate whether current symptoms are the result of the tumor or scar tissue. The nurse would prepare the client for which test? a. Positron emission tomography (PET) b. Three-dimensional biopsy c. Cerebral angiography d. Magnetic resonance imaging (MRI)
a. Positron emission tomography (PET) PET, which measures the brain's activity rather than simply its structure, is useful in differentiating tumor from scar tissue or radiation necrosis. Computer-assisted stereotactic (three-dimensional) biopsy is being used to diagnose deep-seated brain tumors. Cerebral angiography provides visualization of cerebral blood vessels and can localize most cerebral tumors. MRI is the gold standard for detecting brain tumors (particularly smaller lesions) and tumors in the brainstem and pituitary regions, where bone is thick. Ch. 65: Management of Patients with Oncologic or Degenerative Neurologic Disorders - Page 2117
The geriatric advanced practice nurse (APN) is doing client teaching with a client who has had a cerebrovascular accident (CVA) and the client's family. One concern the APN addresses is a potential for falls related to the CVA and resulting muscle weakness. What would be most important for the APN to include in teaching related to this concern? a. Remove throw rugs and electrical cords from home environment. b. Use of tripod cane. c. Need for support group due to decreased self image related to restricted mobility. d. Leg exercises to strengthen muscle weakness.
a. Remove throw rugs and electrical cords from home environment. Client and family teaching is essential and focuses on the following points: Remove throw rugs, clutter, and electrical cords from the client's home environment to reduce the potential for falls. Although the other interventions may be appropriate, they are not as directly related to reducing fall risk. Ch. 62: Management of Patients with Cerebrovascular Disorders
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? a. XII b. IX c. VI d. IV
a. XII 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." The trochlear nerve (IV) is responsible for extraocular movement (inferior medial). The glossopharyngeal nerve (IX) is responsible for swallowing movements and throat sensations. It's also responsible for taste in the posterior third of the tongue. The abducent nerves (VI) are responsible for lateral extraocular movements. Ch. 60: Assessment of Neurologic Function - Page 1972
A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. This CPP reading is considered a. low. b. inaccurate. c. within normal limits. d. high.
a. low. Normal cerebral perfusion pressure (CPP) is 70 to 100 mm Hg. A CPP of 40 mm Hg is low. Ch. 61: Management of Patients with Neurologic Dysfunction - Page 2000
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? a. CN IV b. CN I c. CN III d. CN II
b CN I Cranial nerve (CN) I is the olfactory nerve, which allows the sense of smell. Testing of CN I is done by having the patient identify familiar odors with eyes closed, testing each nostril separately. An inability to smell an odor is a significant finding, indicating dysfunction of this nerve. Ch. 60: Assessment of Neurologic Function - Page 1972
A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client? a. A two-bed room with a client who previously had bacterial meningitis b. An isolation room three doors from the nurses' station c. A private room down the hall from the nurses' station d. A semiprivate room with a client who has viral meningitis
b. An isolation room three doors from the nurses' station A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. Immunity to bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease. Ch. 66: Management of Patients with Infectious Diseases - Page 2151
The nurse is caring for a client who is postoperative from surgery for a brain tumor resection. The client has a visitor at the bedside who lowers the head of the bed below 30 degrees. The nurse assesses the client has decreased level of consciousness. What actions should the nurse take? Select all that apply. a. Check for leaks on the surgical site dressing b. Assess for presence of visual changes c. Assess the client for headache d. Review chart to check for high white blood cell count e. Check the client's blood pressure
b. Assess for presence of visual changes c. Assess the client for headache e. Check the client's blood pressure The client is most likely developing increased intracranial pressure (ICP). With suspicion of ICP, the nurse should assess for ominous signs such as hypertension, bradycardia and respiratory depression. These are serious late signs of ICP and constitute an emergency. Headache is thought to be caused by the tumor's invading, compressing, or distorting the pain-sensitive structures or by edema that accompanies the tumor. Thus, headaches are related to intracerebral edema and increasing ICP. Visual changes can result from ICP, which is referred to as papilledema. Papilledema results from edema on the optic nerve due to increased ICP. Leaking at the surgical site do not arise from increase ICP but can be a sign of infection or inflammation and warrant intervention. A high white blood cell count would indicate infection but would not necessarily be linked to ICP. Ch. 65: Management of Patients with Oncologic or Degenerative Neurologic Disorders - Page 2115
Which of the following is the most common side effect of tissue plasminogen activator (tPA)? a. Headache b. Bleeding c. Hypertension d. Increased intracranial pressure (ICP)
b. Bleeding Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness). Headache, increased ICP, and hypertension are not side effects of tPA. Ch. 62: Management of Patients with Cerebrovascular Disorders - Page 2037
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. Toast b. Coffee c. Orange Juice d. Eggs
b. Coffee 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. Ch. 60: Assessment of Neurologic Function - Page 1989
Which of the following cranial nerves is responsible for salivation, tearing, taste, and sensation in the ear? a. Vestibulocochlear b. Facial c. Trigeminal d. Oculomotor
b. Facial The vestibulocochlear (VIII) cranial nerve is responsible for hearing and equilibrium. The oculomotor (III) cranial nerve is responsible for the muscles that move the eye and lid, pupillary constriction, and lens accommodation. The trigeminal (V) cranial nerve is responsible for facial sensation, corneal reflex, and mastication. The facial (VII) nerve controls facial expression and muscle movement, salivation and tearing, taste, and sensation in the ear. Ch. 60: Assessment of Neurologic Function - Page 1972
A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? a. Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess b. Keeping the client in one position to decrease bleeding c. Maintaining the client in a quiet environment d. Positioning the client to prevent airway obstruction
b. Keeping the client in one position to decrease bleeding The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding. Ch. 62: Management of Patients with Cerebrovascular Disorders - Page 2050
A nurse conducts the Romberg test on a client by asking the client to stand with the feet close together and the eyes closed. As a result of this posture, the client suddenly sways to one side and is about to fall when the nurse intervenes and saves the client from being injured. How should the nurse interpret the client's result? a. Negative Romberg test, indicating a problem with body mass b. Positive Romberg test, indicating a problem with equilibrium c. Positive Romberg test, indicating a problem with level of consciousness d. Negative Romberg test, indicating a problem with vision
b. Positive Romberg test, indicating a problem with equilibrium If the client sways and starts to fall during the Romberg test, it indicates a positive result. This means the client has a problem with equilibrium. The examiner or the nurse stands fairly close to the client during the test to prevent the client from falling. The Romberg test is used to assess the client's motor function, including muscle movement, size, tone, strength, and coordination. However, the Romberg test is not used to assess the client's level of consciousness, body mass, or vision. Ch. 60: Assessment of Neurologic Function - Page 1981
A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. His level of consciousness is decreased, and he requires nasopharyngeal suctioning before transport. Which infection control measures are best when caring for this client? a. Use standard precautions, which require gloves for suctioning. b. Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport. c. Take no special precautions for this client. d. Put on gloves, a mask, and eye protection.
b. Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport. Bacterial meningitis is spread through contact with infected droplets. The nurse should wear gloves, a mask, and eye protection when suctioning the client. Additionally, the client should wear a mask when out of the isolation room for diagnostic testing. Standard precautions don't adequately protect staff and other clients from bacterial meningitis. Ch. 66: Management of Patients with Infectious Diseases - Page 2151
Which of the following are clinical manifestations associated with increased intracranial pressure (ICP)? Select all that apply. a. Angina b. Seizures c. Headache d. Papilledema e. Nausea with or without vomiting
b. Seizures c. Headache d. Papilledema e. Nausea with or without vomiting Symptoms of increased intracranial pressure include headache, nausea with or without vomiting, and papilledema. Angina is not associated with increased ICP. Ch. 65: Management of Patients with Oncologic or Degenerative Neurologic Disorders - Page 2115
A client is diagnosed with meningococcal meningitis. The 22-year-old client shares an apartment with one other person. What would the nurse expect as appropriate care for the client's roommate? a. Bedrest at home for 72 hours b. Treatment with antimicrobial prophylaxis as soon as possible c. Admission to the nearest hospital for observation d. No treatment unless the roommate begins to show symptoms
b. Treatment with antimicrobial prophylaxis as soon as possible People in close contact with clients who have meningococcal meningitis should be treated with antimicrobial chemoprophylaxis, ideally within 24 hours after exposure. Ch. 64: Management of Patients with Neurologic Infections, Autoimmune Disorders, and Neuropathies - Page 2090
A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient? a. Within 48 hours after exposure b. Within 24 hours after exposure c. Therapy is not necessary prophylactically and should only be used if the person develops symptoms. d. Within 72 hours after exposure
b. Within 24 hours after exposure People in close contact with patients with meningococcal meningitis should be treated with antimicrobial chemoprophylaxis using rifampin (Rifadin), ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin). Therapy should be started within 24 hours after exposure because a delay in the initiation of therapy limits the effectiveness of the prophylaxis. Ch. 64: Management of Patients with Neurologic Infections, Autoimmune Disorders, and Neuropathies - Page 2090
The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart? a. CN I b. CN III c. CN II d. CN IV
c. CN II The nurse assesses vision and thus the optic nerve (cranial nerve II) by use of a Snellen eye chart. Ch. 60: Assessment of Neurologic Function - Page 1972
There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected with decreased visual fields. a. Cranial Nerve III b. Cranial Nerve I c. Cranial Nerve II d. Cranial Nerve IV
c. Cranial Nerve II The three sensory cranial nerves are I, II and VIII. Cranial nerve II (optic) is affected with decreased visual fields and acuity. Ch. 60: Assessment of Neurologic Function - Page 1972
A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure? a. Sensory b. Absence c. Generalized d. Jacksonian
c. Generalized A generalized seizure causes generalized electrical abnormality in the brain. The client typically falls to the ground, losing consciousness. The body stiffens (tonic phase) and then alternates between episodes of muscle spasm and relaxation (clonic phase). Tongue biting, incontinence, labored breathing, apnea, and cyanosis may also occur. A Jacksonian seizure begins as a localized motor seizure. The client experiences a stiffening or jerking in one extremity, accompanied by a tingling sensation in the same area. Absence seizures occur most commonly in children. They usually begin with a brief change in the level of consciousness, signaled by blinking or rolling of the eyes, a blank stare, and slight mouth movements. Symptoms of a sensory seizure include hallucinations, flashing lights, tingling sensations, vertigo, déjà vu, and smelling a foul odor. Ch. 61: Management of Patients with Neurologic Dysfunction
A critical care nurse is caring for a client with a cerebrovascular accident (CVA) The client is prescribed heparin for treatment. The nurse knows to monitor the client for what adverse effects? a. Migraine attacks b. High blood pressure c. Hemorrhage d. Respiratory distress
c. Hemorrhage A client with a CVA who is given heparin should be monitored for hemorrhage and bleeding at the subcutaneous injection site. Respiratory distress, high blood pressure, or migraine attacks are not likely to occur in such a client. Ch. 62: Management of Patients with Cerebrovascular Disorders
Which is the priority nursing diagnosis when caring for a client with increased ICP who has an intraventricular catheter? a. Risk for infection b. Fluid volume deficit c. Ineffective cerebral tissue perfusion d. Risk for injury
c. Ineffective cerebral tissue perfusion The brain must be adequately perfused to maintain function and prevent long-term disability due to lack of oxygenation. The client is at risk for injury, fluid volume deficit due to a possible fluid restriction to maintain normovolemia, and infection due to the placement of the intraventricular catheter, but these are not the priority. Ch. 61: Management of Patients with Neurologic Dysfunction - Page 2010
The nurse working on a neurological unit is mentoring a nursing student who asks about a client who has sustained primary and secondary brain injuries. The nurse correctly tells the student which of the following, related to the secondary injury? a. It refers to the difficulties suffered by the client and family related to the changes in the client. b. It results from initial damage to the brain from the traumatic event. c. It results from inadequate delivery of nutrients and oxygen to the cells. d. It refers to the permanent deficits seen after the rehabilitation process.
c. It results from inadequate delivery of nutrients and oxygen to the cells. Secondary injury results from inadequate delivery of nutrients and oxygen to the cells, usually as a result of cerebral edema and increased intracranial pressure. Primary injury results from initial damage related to the traumatic event. Ch. 63: Management of Patients with Neurologic Trauma - Page 2056
Which of the following is an age-related change in the nervous system? a. Increased cerebral blood flow b. Increased myelin c. Loss of neurons in the brain d. More efficient temperature regulation
c. Loss of neurons in the brain Structural changes include loss of neurons in the brain, reduced cerebral blood flow, less efficient temperature regulation, and decreased myelin, resulting in decreased nerve conduction in some nerves. Ch. 60: Assessment of Neurologic Function - Page 1984
An 83-year-old woman suffers a stroke at home and is hospitalized for treatment and management. Which of the following diagnostic procedures would be best to visualize the extent of damage? a. Computed tomography (CT) b. Magnetic resonance imaging (MRI) c. Magnetic resonance angiography (MRA) d. Diffusion-weighted imaging (DWI)
c. Magnetic resonance angiography (MRA) An MRA allows separate visualization of the cerebral vasculature and can be used in place of an MRI. Ch. 60: Assessment of Neurologic Function - Page 1986
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? a. Suggest a nurse or an examiner who is of their age b. Spread the examination over 2 or 3 days c. Provide brief instructions, one step at a time d. Offer incentives such as sweets
c. Provide brief instructions, one step at a time 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. Ch. 60: Assessment of Neurologic Function - Page 1985
A client with CVA is prescribed medication to treat the disorder. The client wants to know what other measures may help reduce CVA. Which is an accurate suggestion for the client? a. Increase hydration and the intake of fluids b. Increase intake of proteins and carbohydrates c. Reduce hypertension and high blood cholesterol d. Increase body weight moderately
c. Reduce hypertension and high blood cholesterol CVAs are prevented by reducing certain risk factors, such as hypertension, overweight, cardiac dysrhythmias like atrial fibrillation, and high blood cholesterol. Clients should not gain body weight. In addition, increased intake of proteins, carbohydrates, or fluids does not help reduce the risk of CVAs. Ch. 62: Management of Patients with Cerebrovascular Disorders
The nurse is aware that, when assessing a patient for symptoms of a brain tumor, the symptom most frequently found is: a. Vertigo and fainting. b. Sharp, unrelenting headaches. c. Simple to generalized seizures. d. Unilateral loss of motor coordination.
c. Simple to generalized seizures. Seizures are usually the first symptom of a brain tumor. Ch. 65: Management of Patients with Oncologic or Degenerative Neurologic Disorders - Page 2115
The nurse is preparing the client for a diagnostic test to evaluate blood flow within intracranial blood vessels. For which test is the nurse preparing the client? a. Cerebral angiography b. Computed tomography c. Transcranial Doppler d. Magnetic resonance imaging
c. Transcranial Doppler Transcranial Doppler flow studies are used to study a tumor's blood flow within intracranial blood vessels. Cerebral angiography may be used to study a tumor's blood supply or obtain information about vascular lesions. Magnetic resonance imaging provides information similar to that provided by computed tomography, but with improved tissue contrast, resolution, and anatomic definition, and it examines the lesion in multiple planes. Ch. 60: Assessment of Neurologic Function - Page 1988
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? a. III b. VIII c. X d. VII
c. X 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. CN VII is the facial nerve and has to do with symmetry of facial movements and the ability to discriminate between the tastes of sugar and salt. The inability to close one eyelid indicates impairment of this nerve. CN VIII is the acoustic nerve. It has to do with hearing, air and bone conduction, and balance. CN III is the oculomotor nerve and has to do with pupillary response, conjugate movements, and nystagmus. Ch. 60: Assessment of Neurologic Function - Page 1972
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 cerebrum. b. risk for increased intracranial pressure. c. dysfunction in the brain stem. d. dysfunction in the spinal column.
c. dysfunction in the brain stem. 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. Ch. 60: Assessment of Neurologic Function - Page 1976
To meet the sensory needs of a client with viral meningitis, the nurse should: a. promote an active range of motion. b. avoid physical contact between the client and family members. c. minimize exposure to bright lights and noise. d. increase environmental stimuli.
c. minimize exposure to bright lights and noise. Photophobia and hypersensitivity to environmental stimuli are the common clinical manifestations of meningeal irritation and infection. Therefore, the nurse should provide a calm environment with less stressful stimuli. Physical activity may worsen symptoms; therefore, physical activity should be reduced. Family members do not need to be avoided. People diagnosed with viral meningitis should be instructed to thoroughly wash hands frequently. Ch. 61: Management of Patients with Neurologic Dysfunction - Page 2027
A nurse is preparing a client for a computed tomography (CT) scan that requires infusion of radiopaque dye. Which question is the most important for the nurse to ask? a. "When did you last take any medication?" b. "How much do you weigh?" c. "When did you last have something to eat or drink?" d. "Are you allergic to seafood or iodine?"
d. "Are you allergic to seafood or iodine?" Seafood and the radiopaque dye used in CT contain iodine. To prevent an allergic reaction to the radiopaque dye, the nurse should ask the client about allergies to seafood or iodine before the CT scan. Because fasting is unnecessary before a CT scan, the nurse doesn't need to obtain information about the client's last food and fluid intake. The client's last dose of medication and current weight also are irrelevant. Ch. 60: Assessment of Neurologic Function - Page 1986
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
d. A normal finding; the fluid will be sent for testing to determine other factors 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. Ch. 60: Assessment of Neurologic Function - Page 1990
When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? a. Continue the assessment because no actions are indicated at this time. b. Contact the physician to review the care plan. c. Document the reading because it reflects that the treatment has been effective. d. Check the equipment.
d. Check the equipment. A reading of 0 mm Hg indicates equipment malfunction. The nurse should check the equipment and report problems. Normal and stable ICP values are less than 15 mm Hg. Some pressure is always present in the cranial vault. The nurse shouldn't contact the physician to review the care plan at this time. The nurse needs to complete the assessment of the client and equipment before making a report to the physician. Ch. 61: Management of Patients with Neurologic Dysfunction - Page 2000
A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first? a. Involuntary posturing b. Pupillary asymmetry c. Irregular breathing pattern d. Declining level of consciousness (LOC)
d. Declining level of consciousness (LOC) With a brain injury such as an epidural hematoma (a likely diagnosis, based on this client's symptoms), the initial sign of increasing ICP is a change in LOC. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will occur. Ch. 61: Management of Patients with Neurologic Dysfunction - Page 2001
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? a. Completed Stroke b. Right-sided cerebrovascular accident (CVA) c. Transient ischemic attack (TIA) d. Left-sided cerebrovascular accident (CVA)
d. Left-sided cerebrovascular accident (CVA) When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete. Ch. 62: Management of Patients with Cerebrovascular Disorders
In reviewing a client's history and physical examination, a nurse finds that the client was found positive for ataxia during the physician's neurological testing. Which nursing diagnosis will be a priority for this client? a. Autonomic dysreflexia b. Deficient fluid volume c. Risk for infection d. Risk for falls
d. Risk for falls Ataxia means incoordination of voluntary muscle action, particularly involving those muscles used in walking. This client will be at risk for falls. There is no indication that this client has a risk for infection, low fluid volume, or autonomic dysreflexia. Ch. 60: Assessment of Neurologic Function - Page 1981
A high school soccer player sustained five concussions before she was told that she should never play contact sports again. After her last injury, she began experiencing episodes of double vision. She was told that she had most likely incurred damage to which cranial nerve? a. VII (Facial) b. V (Trigeminal) c. IV (Trochlear) d. VI (Abducens)
d. VI (Abducens) The abducens cranial nerve supports movement of the eye laterally. Damage to the nerve can cause double vision. Ch. 60: Assessment of Neurologic Function - Page 1972
A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with: a. thinking and reasoning. b. visual acuity. c. balance and equilibrium. d. body temperature control.
d. body temperature control. The body's thermostat is located in the hypothalamus; therefore, injury to that area can cause problems with body temperature control. Balance and equilibrium problems are related to cerebellar damage. Visual acuity problems would occur following occipital or optic nerve injury. Thinking and reasoning problems are the result of injury to the cerebrum. Ch. 60: Assessment of Neurologic Function - Page 1973
For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to: a. lower arterial pH. b. prevent respiratory alkalosis. c. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg. d. promote carbon dioxide elimination.
d. promote carbon dioxide elimination. The goal of treatment for ICP is to prevent acidemia by eliminating carbon dioxide because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this client. It isn't necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients. Ch. 61: Management of Patients with Neurologic Dysfunction - Page 2000
