AHN 2: Neurologic dysfunction

XII

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? IX IV XII VI

Temporal lobe

Damage to which area of the brain results in receptive aphasia? Parietal lobe Temporal lobe Occipital lobe Frontal lobe

support the joint where the tendon is being tested

During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to: hold the reflex hammer tightly. support the joint where the tendon is being tested. use the pointed end of the reflex hammer when striking the Achilles tendon. tap the tendon slowly and softly.

transmits motor impulses from the brain to the spinal cord

The brain stem holds the medulla oblongata. What is the function of the medulla oblongata? controls striated muscle activity in blood vessel walls controls parasympathetic nerve impulses in the pons transmits sensory impulses from the brain to the spinal cord transmits motor impulses from the brain to the spinal cord

15%

The cerebral circulation receives approximately what percentage of the cardiac output? 20% 25% 10% 15%

Twelve

The spinal cord is composed of 31 pairs of spinal nerves. How many pairs of thoracic nerves are contained within the spinal column? Five One Eight Twelve

Fourth ventricle

Which anatomic part supplies cerebrospinal fluid to the subarachnoid space and down the spinal cord on the dorsal surface? Arachnoid villus Lateral ventricle Third ventricle Fourth ventricle

decorticate posture

characteristic posture associated with a lesion at or above the upper brain stem. The patient presents with the arms flexed, fists clenched, and legs extended.

Decerebrate posture

sustained contraction of extensor muscles of the extremities resulting from a lesion in the brainstem. The patient presents with stiff and extended extremities and retracted head.

VIII

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 VI XI II

Motor

Which neurons transmit impulses from the CNS? Neurilemma Dendrites Sensory Motor

Left frontoparietal region

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 basal ganglia Left frontoparietal region Right frontoparietal region Left temporal region

pons.

A patient is treated for a neurologic dysfunction affecting facial expressions. The affected cranial nerve originates in the: midbrain. cerebral hemisphere. medulla. pons.

Occipital

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 Occipital Frontal Parietal

Inferior posterior frontal areas

A patient has expressive speaking aphasia after having a stroke. Which portion of the brain does the nurse know has been affected? Parietal-occipital area Inferior posterior frontal areas Posterior frontal area Temporal lobe

Oculocephalic Reflex

"Doll's Head" movement assessing brainstem integrity in comatose patients

Romberg Test

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 Romberg test Heel-to-toe test Carlsberg test

Lateral recumbent with thighs flexed

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure? Prone, with the head turned to the right Lateral, with right leg flexed Lateral recumbent, with thighs flexed Supine, with the knees raised toward the chest

response due to interrupted impulses from the central nervous system

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: 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. processing information transferred from the environment.

V

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? IV V VI III

flaccid muscles

Lower motor neuron lesions cause increased muscle tone. no muscle atrophy. hyperactive and abnormal reflexes. flaccid muscles.

Unequal pupils Absence of pupillary response Pinpoint pupils

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. Pupil reaction quick Unequal pupils Pupil reacts to light Absence of pupillary response Pinpoint pupils

Constricted pupils

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 One pupil is dilated and the opposite pupil is normal Roth's spots Dilated pupils

When, if any, was your last narcotic use?

When completing a neurologic examination on a client, which question is most essential to evaluate the accuracy of the data? Have you been diagnosed with any mental health issues? When, if any, was your last narcotic use? Have you experienced any unusual sensations? Do you have any history of forgetfulness?

Temporal

Which cerebral lobe contains the auditory receptive areas? Temporal Frontal Parietal Occipital

Trigeminal

Which cranial nerve is responsible for facial sensation and corneal reflex? Vestibulocochlear Trigeminal Oculomotor Facial

Transcranial Doppler

Which diagnostic test may be performed to evaluate blood flow within intracranial blood vessels? Transcranial Doppler Cerebral angiography Magnetic resonance imaging Computed tomography

turning the client's head suddenly while holding the eyelids open.

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:

Cranial nerve XII

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 I Cranial nerve XI Cranial nerve V

cerebral angiography

The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm? Cerebral angiography Echoencephalography Electroencephalogram Myelogram

VIII

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 III VII X

Heartbeat to decrease

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? Heartbeat to decrease Blood vessels in the heart muscle to dilate Blood vessels in the skeletal muscles to dilate Blood pressure to increase

Cranial nerve II

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

"Do you have any problems with balance?"

To evaluate a client's cerebellar function, a nurse should ask: "Do you have any difficulty speaking?" "Do you have any problems with balance?" "Do you have any trouble swallowing food or fluids?" "Have you noticed any changes in your muscle strength?"

Acetylcholine

Which of the following neurotransmitters are deficient in myasthenia gravis? Dopamine Serotonin GABA Acetylcholine

Withhold anticonvulsant medications for 24 to 48 hours before the exam

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 Maintain NPO status for 6 hours before the procedure Sedate the client before the procedure, per orders Instruct the client that a standard EEG takes 2 hours

Allow the client to rest and shampoo the client's hair.

A client undergoes a scheduled electroencephalogram (EEG). Which of the following post-procedure activities should the nurse carry out for the client? Measure the level of consciousness (LOC) of the client. Measure the heart and the pulse rate. Allow the client to rest and shampoo the client's hair. Provide the client with adequate caffeine-rich drinks.

cranial nerves IX & X

During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates: cranial nerves IX and X. cranial nerves I and II. cranial nerves VI and VIII. cranial nerves III and V.

Comatose

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? Somnolence Normal Stupor Comatose

Tell the client to expect some discomfort.

The nurse is caring for a client in the clinic who has come in to have an EMG done. How would the nurse prepare the client for this test? Tell the client the doctor will use fluoroscopy for this test. Tell the client they will have to lie flat afterwards. Tell the client the test is painless. Tell the client to expect some discomfort.

In the spinal cord

A comatose client is being cared for by a critical care nurse who documents that the client responds only to very painful stimuli by fragmentary, delayed reflex withdrawal. The nurse knows that reflexes in the body are centered where? In the medulla oblongata In the midbrain In the spinal cord In the pons

Facial

Which of the following cranial nerves is responsible for salivation, tearing, taste, and sensation in the ear? Oculomotor Vestibulocochlear Trigeminal Facial

Parkinson's disease

Which of the following is a disorder due to a lesion in the basal ganglia? Parkinson's disease Guillain-Barré Multiple sclerosis Myasthenia gravis

dysfunction in the brain stem.

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates: risk for increased intracranial pressure. dysfunction in the cerebrum. dysfunction in the brain stem. dysfunction in the spinal column.

Contrast will be given and a rapid sequence of radiographs will be taken.

A client suspected of having a distortion of cerebral arteries and veins is scheduled for a cerebral angiography. What would the nurse tell the client about the upcoming test? That sedatives, coffee, tea, and soft drinks that contain caffeine will be withheld for at least 8 hours before the test to avoid affecting the diagnostic findings. The client will have to stay in a dark quiet room. Contrast will be given and a rapid sequence of radiographs will be taken. The client will have to shampoo his or her hair.

Head of bed elevated 45 degrees

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 Supine with the head lower than the trunk Supine with feet raised Prone

"It can mean a traumatic puncture or a subarachnoid bleed."

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 bleed around the hypothalamus or damage from the needle." "It can mean the spinal cord was damaged or a traumatic puncture." "It can mean a subarachnoid bleed or damage to the spinal cord." "It can mean a traumatic puncture or a subarachnoid bleed."

Get plenty of bed rest Take some OTC analgesics Force fluids (unless contraindicated)

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. Get plenty of bed rest. Limit the amount of fluid to decrease cerebral edema. Take some over-the-counter analgesics. Walk around. Force fluids (unless contraindicated).

Brain stem

A patient who has suffered a stroke is unable to maintain respiration and is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe? Brain stem Occipital lobe Frontal lobe Parietal lobe

Flaccidity

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? Weak muscular tone Flaccidity Decorticate posturing Abnormal posture

Allergic reaction to the imaging material

The nurse is caring for a client who is undergoing single-photon emission computed tomography (SPECT). What is a potential side effect that this client may suffer? Claustrophobia Headache and pain in the neck Allergic reaction to radioactive rays Allergic reaction to the imaging material

Moving head and chin towards chest

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? Lightly tapping the lower portion of the neck to detect sensation Moving the head toward both sides Moving the head and chin toward the chest Gently pressing the bones on the neck

Parietal

Which lobe of the brain is responsible for spatial relationships? Temporal Frontal Parietal Occipital

Clonus

Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed? Clonus Ataxia Rigidity Flaccidity

Serotonin

Which neurotransmitter demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways? Serotonin Enkephalin Acetylcholine Norepinephrine

Muscle contraction is palpable and visible.

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

hypoxia

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. fever. hypoxia. visual disturbance.