CH 65 Assessment of Neurologic Function
The normal adult produces about ___________mL of cerebrospinal fluid daily from the ventricles
150
Cranial nerve VI
Abducens- eye movement
The preganglionic fibers of the sympathetic neurons are located in the segments of the spinal cord identified as _________ to _________.
C8 to L3
What clinical manifestations occur when there is destruction or dysfunction in the basal ganglia?
Destruction or dysfunction of the basal ganglia leads not to paralysis but to muscle rigidity, disturbances of posture, and difficulty initiating or changing movement
Affects behavior, attention, and fine movement
Dopamine
Excitatory; inhibits pain transmission
Enkephalin
Cranial nerve VII
Facial - controls most facial expressions & secretion of tears & saliva & taste
Name the principle signs of lower motor neuron disease
Flaccid paralysis and atrophy of the affected muscles
Cranial nerve IX
Glossopharyngeal - taste & senses carotid blood pressure
Excitatory response, mostly affecting moods
Norepinephrine
Cranial nerve III
Oculomotor- eye movement
Cranial nerve I
Olfactory (smell)
Cranial nerve II
Optic - vision
Inhibits pain pathways and can control sleep
Serotonin
Cranial nerve XI
Spinal Accessory - controls trapezius & sternocleidomastoid & controls swallowing movements
Describe the role and functions of the autonomic nervous system
The autonomic nervous system regulated the activities of internal organs such as the heart, lungs, blood vessels, digestive organs, and glands. Maintenance and restoration of internal homeostasis is largely and responsibility of the autonomic nervous system
Cranial nerve V
Trigeminal - chewing face & mouth touch & pain
Cranial nerve X
Vagus - senses aortic blood pressure & slows heart rate & stimulates digestive organs & taste
Cranial nerve VIII
Vestibulocochlear: hearing and equilibrium
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 MRI? a. "I am trying to quit smoking and have a patch on" b. "I have been trying to get an appointment for so long" c. "I have not had anything to eat or drink since 3 hours ago" d. "My legs go numb sometimes when I sit too long"
a. "I am trying to quit smoking and have a patch on"
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 1 b. CN 2 c. CN 3 d. CN 4
a. CN 1
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? a. Frontal lobe b. Parietal lobe c. Occipital lobe d. Temporal lobe
a. Frontal lobe
The parasympathetic division of the autonomic nervous system yields impulses that are mediated by the secretion of ___________, the dominant neurotransmitter in parasympathetic nervous system functions
acetylcholine
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, the nurse observes diminished or hypoactive reflexes. How will the nurse document this finding? a. 0 b. 1+ c. 2+ d. 3+
b. 1+
The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using this chart? a. CN 1 b. CN 2 c. CN 3 d. CN 4
b. CN 2
The nurse is assessing the pupils of a patient who has had a head injury. What does the nurse recognize as a parasympathetic effect? a. Dilated pupils b. Constricted pupils c. One pupil is dilated and the opposite pupil is normal d. Roth spots
b. Constricted pupils
A patient is scheduled for an electroencephalogram (ERG) in the morning. What food on the patient's tray should the nurse remove prior to the test? a. Orange juice b. Toast c. Coffee d. Eggs
c. Coffee
The nurse is performing a neurologic assessment and requests that the patient stand with eyes open and then closed for 20 seconds to assess balance. What type of test is the nurse performing? a. Weber test b. Rinne test c. Romberg test d. Watch-tick test
c. Romberg test
The nurse is assisting with a lumbar puncture and observes that when the healthcare provider obtains cerebrospinal fluid, it is clear and colorless. What does the finding indicate? a. A subarachnoid hemorrhage b. Severe sepsis c. This is a normal finding; the fluid will be sent for testing to determine other factors d. Local trauma from the insertion of the needle
c. This is a normal finding; the fluid will be sent for testing to determine other factors
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? a. III b. IV c. V d. VI
c. V
The brain cortex responsible for balancing and coordination is the _________
cerebellum
A patient who has suffered a stroke is unable to maintain respiration and so is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breath? a. Frontal lobe b. Occipital lobe c. Parietal lobe d. Brain stem
d. Brain stem
A patient is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the patient has? a. Dysfunction of the spinal accessory nerve b. Dysfunction of the acoustic nerve c. Dysfunction of the facial nerve d. Dysfunction of the vagus nerve
d. Dysfunction of the vagus nerve
Parkinson disease is caused by an imbalance in the neurotransmitter known as
dopamine
A person's personality and judgement are controlled by the area of the brain known as the
frontal lobe
Voluntary muscle control is governed by a vertical band of "motor cortex" located in the
frontal lobe
Muscle and nerve inhibitory transmissions
gamma-aminobutyric acid
Cranial nerve XII
hypoglossal nerve- tongue movement
The sleep-wake cycle regulator and the site of the hunger center is known as the
hypothalamus
The "master gland" is also known as the
pituitary gland
A neurotransmitter that helps control mood and sleep
serotonin
The lobe of the cerebral cortex that is responsible for the understanding of language and music is the
temporal lobe
The major receiving and communication center for afferent sensory nerves is the
thalamus
Cranial nerve IV
Trochlear- eye movement
Primarily excitatory; can produce vagal stimulation of heart
Acetylcholine
What is the function of the blood-brain barrier?
This barrier is formed by the endothelial cells of the brain's capillaries, which form continuous tight junctions, creating a barrier to macromolecules and many compounds
A patient has expressive speaking aphasia after having a stroke. Which portion of the brain does the nurse know has been affected? a. Temporal lobe b. Inferior posterior frontal areas c. Posterior frontal area d. Parietal-occipital lobe
b. Inferior posterior frontal areas
A patient had a lumbar puncture 3 days ago in the outpatient clinic and calls the nurse reporting a throbbing headache. What can the nurse educate the patient to do for relief of the discomfort? (Select all that apply.) a. Limit the amount of fluid to decrease cerebral edema b. Force fluids (unless contraindicated) c. Take some over-the-counter analgesics d. Walk around
b. Force fluids (unless contraindicated) c. Take some over-the-counter analgesics d. Walk around
A patient is having a lumbar puncture and the healthcare provider has removed 20 mL of cerebrospinal fluid. What nursing intervention is a priority after the procedure? a. Early ambulation b. Have the patient lie flat for 6 hours c. Have the patient lie flat for 1 hour and then sit for 1 hour before ambulating d. Have the patient lie in a semi-fowler position with the HOB at 30 degrees
b. Have the patient lie flat for 6 hours