Chapter 19 Nervous System

Which cranial nerve connects with the brain at the junction of the pons and the medulla? A. Facial nerve B. Olfactory nerve C. Trochlear nerve D. Oculomotor nerve

A. Facial nerve Rationale The facial nerve connects with the brain at the junction of the pons and the medulla. The olfactory nerve connects with the anterior ventral cerebrum. The trochlear nerve and oculomotor nerve connect at the midbrain. p. 1297

Which diagnostic study is used to obtain cerebral spinal fluid (CSF)? A. Lumbar puncture B. Transcranial Doppler C. Computerized tomography (CT) scan D. Positron emission tomography (PET) scan

A. Lumbar puncture Rationale CSF is obtained via lumbar puncture. A PET scan measures metabolic activity of the brain to assess cellular death or damage. A transcranial Doppler is used to evaluate blood flow of the intracranial blood vessels. A CT scan provides radiographic images of the brain. Test-Taking Tip: Begin studying two to three months in advance. Schedule study time each day. Set up a study schedule of topics. p. 1309

The nurse is caring for a patient who has experienced an optic nerve injury after a trauma. Which condition does the nurse recognize is associated with this type of injury? A. Dysarthria B. Anisocoria C. Nystagmus D. Hemiplegia

B. Anisocoria Rationale Anisocoria is a condition caused by an optic nerve injury, in which the pupil of one eye differs in size from the pupil of the other. Dysarthria is associated with the presence of lesions in the cranial nerve. Nystagmus and hemiplegia are muscular disorders. Lesions in the cerebellum, brain stem, or vestibular system cause nystagmus. Hemiplegia is caused due to the presence of lesions in the motor cortex. p. 1308

Which patient's findings may indicate Alzheimer's disease, based on review of the diagnostic test results of four patients by the nurse? A. Patient A: Deficiency of acetylcholine-secreting neurons B. Patient B: Deficiency of y-aminobutyric acid C. Patient C: Increased intracranial pressure D. Patient D: Cerebral cortex incision

A. Patient A: Deficiency of acetylcholine-secreting neurons Rationale Alzheimer's disease is a progressive mental deterioration condition that occurs due to generalized degeneration of the brain. Decreased acetylcholine-secreting neurons cause Alzheimer's disease. Deficiency of γ-aminobutyric acid may cause seizure disorder in Patient B. Increased intracranial pressure (ICP) in Patient C may cause herniation syndrome. A cerebral cortex lesion in Patient D may cause apraxia. p. 1337

What is the rating on the muscle response scale of 0 to 5 when an elicited patellar reflex is brisk? A. 0 B. 2 C. 3 D. 5

C. 3 Rationale A patellar reflex that is brisk is rated a 3. A rating of a 0 is an absent reflex, and a 2 is a normal response. A muscle response rated a 5 is hyperreflexic with sustained clonus. p. 1307

Which neurotransmitter is released by both preganglionic and postganglionic nerve endings of the sympathetic nervous system (SNS)? A. Serotonin B. Dopamine C. Acetylcholine D. Norepinephrine

C. Acetylcholine Rationale Acetylcholine is released by the preganglionic and postganglionic nerve endings of the SNS. Serotonin and dopamine are released by preganglionic fibers. Norepinephrine is released by postganglionic fibers of the SNS. p. 1295

A nurse is assessing the mental status of a patient. By what criteria should the nurse judge the mental status of the patient? Select all that apply. A. Alert and oriented B. Intact sense of smell C. Pupils reactive to light D. Midline protrusion of tongue E. Appropriate mood and affect

A. Alert and oriented E. Appropriate mood and affect Rationale The patient's alertness and orientation along with appropriate mood and affect help the nurse assess the mental status of the patient. An intact sense of smell, reaction of pupils to light, and a midline protrusion of the tongue suggest normal functioning of associated cranial nerves. p. 1304

A patient has an alteration in sleep-wake transitions causing extreme fatigue. Which part of the central nervous system (CNS) is responsible for this? A. Cerebrum B. Brain stem C. Cerebellum D. Spinal cord

B. Brain stem Rationale The brain stem includes the reticular activating system (RAS), which is responsible for regulating arousal and sleep-wake transitions. The cerebrum is responsible for the integration of complex sensory and neural functions, initiation, and coordination of voluntary activity. The cerebellum coordinates voluntary movement and maintains trunk stability and equilibrium. The spinal cord aids in transmission of neural signals between the brain and the rest of the body. p. 1297

A patient is admitted to the hospital with suspected lesions in Broca's area. What manifestation is the nurse likely to find during assessment? A. Visual defects B. Difficulty in swallowing C. Irregular speech patterns D. Decreased sense of smell

C. Irregular speech patterns Rationale Broca's area, located at the frontal lobe of the cerebrum, regulates verbal expression. Lesions in Broca's area affect speech production. Visual defects are common if the lesion is in the occipital lobe. Damage to the olfactory bulb may affect the sense of smell. Brainstem injuries may cause difficulty in swallowing. p. 1296

The nurse is educating the patient who is scheduled for an electromyography (EMG). What information should the nurse provide to the patient? A. "You will be sedated for this procedure." B. "You will experience a series of electrical stimuli." C. "You will have a series of patches applied to your skin." D. "You will be asked to tighten certain muscles for electrical measurement."

D. "You will be asked to tighten certain muscles for electrical measurement." Rationale An EMG is the recording of electrical activity associated with innervation of skeletal muscles. Needle electrodes are inserted into the muscle to record electrical activity with muscle contraction. Because muscles at rest show no electrical activity, the patient will be asked to tighten (contract) muscle groups to record electrical activity. The patient must be awake to cooperate with this examination. Electrical stimuli are not applied to the muscles for this test. No patches will be applied to the skin. p. 1311

Which cranial nerve is responsible for pupillary constriction? A. II B. III C. IV D. V

B. III Rationale Cranial nerve III (oculomotor) is responsible for pupillary constriction. Cranial nerve II (optic) is the sensory nerve to the retina of eyes and is responsible for vision. Cranial nerve IV (trochlear) controls motor eye movement. Cranial nerve V (trigeminal) is a sensory motor nerve that has ophthalmic, maxillary, and mandibular branches. p. 1305

When assessing motor function of a patient admitted with a stroke, the nurse identifies mild weakness of the arm demonstrated by downward drifting of the arm. How should the nurse most accurately document this finding? A. Athetosis B. Hypotonia C. Hemiparesis D. Pronator drift

D. Pronator drift Rationale Downward drifting of the arm or pronation of the palm is identified as a pronator drift. Athetosis is a slow, writhing, involuntary movement of the extremities. Hypotonia is flaccid muscle tone, and hemiparesis is weakness of one side of the body. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. p. 1306

The nurse is performing a pupillary assessment in an unconscious patient. Which functions will the nurse be able to accurately assess? Select all that apply. A. Size B. Shape C. Reactivity D. Convergence E. Accommodation

A. Size B. Shape C. Reactivity Rationale Pupil size, shape, and reactivity can be assessed in the unconscious patient. Pupil convergence and accommodation require that the patient focus on the examiner's finger as it moves toward the patient's nose. Test-Taking Tip: If you are unable to answer a multiple choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multiple response question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response. p. 1306

After a lumbar puncture, the nurse sends the cerebrospinal fluid for investigation. What findings are considered normal for cerebrospinal fluid? Select all that apply. A. pH 7.35 B. Glucose 50 mg/dL C. Specific gravity 1.007 D. Red blood cells 15 cells/μL E. White blood cells 10 cells/μL

A. pH 7.35 B. Glucose 50 mg/dL C. Specific gravity 1.007 Rationale The normal values of cerebrospinal fluid parameters include specific gravity of 1.007, glucose level of 50 mg/dL, and pH of 7.35. The presence of more than five white blood cells/μL in the cerebrospinal fluid indicates infection. The presence of red blood cells in the cerebrospinal fluid indicates bleeding. p. 1309

Which is an expected finding in the geriatric patient resulting from a change in the reticular activating system (RAS)? A. Cerebral tissue atrophy B. Decrease in stage 4 sleep C. Decrease in sensory receptors D. Slowed autonomic nervous system (ANS) responses

B. Decrease in stage 4 sleep Rationale Decreases in stage 4 sleep are a result of age-related changes in the RAS. The RAS is responsible for regulating arousal and sleep-wake transitions. A decrease in the sensory receptors is caused by change in the motor sensory division. Cerebral tissue atrophy is a result of changes in the brain, and the slowed ANS responses are caused by changes in the ANS. p. 1302

Which neurotransmitters inhibit the transmission of impulses across the synaptic cleft? Select all that apply. A. GABA B. Serotonin C. Glutamate D. Dopamine E. Endorphins F. Epinephrine

A. GABA B. Serotonin D. Dopamine Rationale GABA, serotonin, and dopamine are neurotransmitters that inhibit the transmission of impulses across the synaptic cleft. Endorphins block pain transmission. Glutamate and epinephrine are excitatory neurotransmitters that activate postsynaptic receptors that increase the likelihood that an action potential will be generated. p. 1295

The nurse educator is teaching a group of nursing students about the anatomy and physiology of the nervous system. The educator asks which glial cells are most abundant, primarily found in the gray matter, and provide structural support to neurons. Which response is correct? A. "Astrocytes" B. "Microglial cells" C. "Ependymal cells" D. "Oligodendrocytes"

A. "Astrocytes" Rationale Astrocytes are the most abundant glial cells. They are found primarily in the gray matter and provide structural support to neurons. Astrocytes are macroglial cells. The delicate processes of astrocytes form the blood-brain barrier with the endothelium of the blood vessels. Microglial cells are specialized macrophages capable of phagocytosis. Ependymal cells line the ventricles of the brain and help in the secretion of cerebrospinal fluid. Oligodendrocytes are specialized cells that produce the myelin sheath in the central nervous system; they are mainly found in the white matter of the brain. Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer. p. 1294

During a neurologic assessment, the nurse tests the functionality of the facial nerve. What instructions should the nurse give to the patient? Select all that apply. A. Frown B. Raise the eyebrows C. Protrude the tongue D. Read a Snellen chart E. Move the tongue side to side

A. Frown B. Raise the eyebrows Rationale Asymmetry in facial movements indicates damage to the facial nerve. When assessing cranial nerve VII (the facial nerve), the patient is asked to raise the eyebrows and frown and may also be asked to close the eyes tightly or purse the lips. A Snellen chart is used to test visual acuity, and protrusion of the tongue or moving the tongue from side to side assesses the hypoglossal nerve. p. 1305

The nurse provides education to a group of students about the effects of aging on the nervous system. Which statement made by a student indicates the need for further teaching? A. "Cerebrospinal fluid production decreases due to constriction of ventricles." B. "Coordination of neuromuscular activity to maintain body temperature is less efficient." C. "Loss of myelin and a decrease in conduction time occur in the peripheral nervous system." D. "Cerebral tissue atrophy and increased size of ventricles occur in the central nervous system."

A. "Cerebrospinal fluid production decreases due to constriction of ventricles." Rationale Cerebrospinal fluid (CSF) production decreases due to enlargement of ventricles. When the ventricles widen or enlarge, the brain weight decreases, cerebral blood flow decreases, and CSF production declines. Coordination of neuromuscular activity to maintain body temperature is less efficient with aging. Loss of myelin sheath and decrease in conduction occur in cranial and spinal nerves in the peripheral nervous system. Cerebral tissue atrophy and increased size of ventricles occur in the brain within the central nervous system with aging. p. 1302

The nurse provides instructions to a patient who is scheduled for an electroencephalogram (EEG) the following day. What statement made by the patient indicates an understanding of the instructions? A. "I'll wash my hair tonight." B. "I'll need to take a laxative." C. "I plan to go to bed early tonight." D. "I can't eat or drink anything after midnight."

A. "I'll wash my hair tonight." Rationale The patient's hair should be free of oils, sprays, and lotions before an EEG. Oily hair or hair care products may interfere with the conduction of neurologic electrical impulses recorded during an EEG. Therefore patient preparation includes shampooing the hair and refraining from using any other hair products. Taking a laxative, going to bed early, and refraining from eating or drinking after midnight are not required before an EEG. p. 1311

A nurse is teaching a group of caregivers how to assess patients for facial nerve palsy. Which methods of assessment of facial nerve palsy should be included in the teachings? Select all that apply. A. Ask the patient to whistle. B. Pin prick the tip of the nose. C. Ask the patient to protrude the tongue. D. Test the sense of taste on the posterior third of the tongue. E. Ask the patient to shut his or her eyes as tightly as possible.

A. Ask the patient to whistle. E. Ask the patient to shut his or her eyes as tightly as possible. Rationale The facial nerve innervates the muscles of facial expression. It is impossible for a patient with facial palsy to whistle. When the patient with facial palsy closes his or her eyes tightly, the eye affected by a facial nerve palsy may not close properly. A pinprick on the nose will help to test sensation perception. Protrusion of the tongue tests the hypoglossal nerve. The facial nerve is responsible for taste in the anterior two-thirds of the tongue, but the sensory fibers for taste from the posterior third of the tongue are associated with the glossopharyngeal nerve. p. 1305

The health care provider requests cerebral angiography for a patient to detect a potential brain tumor. What should the nurse ensure before the patient goes for the test? Select all that apply. A. Assess the patient for stroke. B. Ensure that the patient has a full bladder. C. Explain that the procedure is noninvasive. D. Instruct that a contrast medium will be injected. E. Ensure that the patient has a full meal before the procedure.

A. Assess the patient for stroke D. Instruct that a contrast medium will be injected Rationale Cerebral angiography is a contrast-based test. The nurse should assess the patient for stroke before the test, because any thrombi, if present, may be dislodged during the procedure. The nurse should explain that a contrast medium will be injected by a small needle into the vein, making this procedure invasive. The patient is asked to empty the bladder before the procedure. The preceding meal should be withheld to prevent aspiration if an adverse reaction to the contrast medium occurs. p. 1310

When assessing a patient with a traumatic brain injury, the nurse notes uncoordinated movement of the extremities. How should the nurse document this assessment? A. Ataxia B. Apraxia C. Anisocoria D. Anosognosia

A. Ataxia Rationale Ataxia is a lack of coordination of movement, possibly caused by lesions of sensory or motor pathways, cerebellum disorders, or certain medications. Apraxia is the inability to perform learned movements despite having the desire and physical ability to perform them related to a cerebral cortex lesion. Anisocoria is inequality of pupil size from an optic nerve injury. Anosognosia is the inability to recognize a bodily defect or disease related to lesions in the right parietal cortex. p. 1306

A nurse is assessing the mental function of a patient with a neurologic disorder. What assessment findings would the nurse recognize should be reported to the primary care provider? Select all that apply. A. Attention is fleeting B. Patient is over talkative C. Patient is well-groomed D. Patient sits comfortably E. Conversation flows easily

A. Attention is fleeting B. Patient is over talkative Rationale Fleeting attention and overtalkativeness imply a disturbance in mental status. If the patient is well-groomed and sits comfortably, this indicates that the patient is aware of his or her appearance and behavior. An easy flow of conversation indicates that the patient can communicate well. p. 1304

The nurse receives a patient suspected of injury to the basal ganglia. What functions would be affected in the patient due to the injury? Select all that apply. A. Blinking B. Sexual response C. Swallowing saliva D. Feeding behavior E. Swinging the arms while walking

A. Blinking C. Swallowing saliva E. Swinging the arms while walking Rationale Any injury to the basal ganglia may adversely affect its function. The function of the basal ganglia includes the initiation, execution, and completion of voluntary movements; learning; emotional responses; and automatic movements associated with skeletal muscle activity like swinging the arms while walking, swallowing saliva, and blinking. Sexual response and feeding behavior are not controlled by basal ganglia; these activities are controlled by the limbic system. p. 1297

Which are components of the central nervous system (CNS)? Select all that apply. A. Cerebrum B. Brainstem C. Spinal cord D. Cerebellum E. Spinal nerves F. Cranial nerves

A. Cerebrum B. Brainstem C. Spinal cord D. Cerebellum Rationale The CNS is made up of the cerebrum (right and left hemispheres), cerebellum, brainstem, and spinal cord. The spinal and cranial nerves are parts of the peripheral nervous system. p. 1296

A patient reports decrease in the sense of smell. What does the nurse suspect could be the possible reasons for this symptom? Select all that apply. A. Heavy smoking B. Basilar skull fracture C. Damage to vagus nerve D. Damage to the trochlear nerve E. Damage to glossopharyngeal nerve

A. Heavy smoking B. Basilar skull fracture Rationale Chemicals in cigarette smoke may damage the olfactory receptor cells, thus affecting the ability to smell. The basilar skull fracture may damage the olfactory fibers as they pass through the delicate cribriform plate of the skull, thus affecting the ability to smell. The vagus nerve has sensory functions on the viscera of the thorax and abdomen. The trochlear nerve is associated with eye movement. The glossopharyngeal nerve is associated with taste sensation and motor activity of the superior pharyngeal muscles. p. 1306

Which cranial nerves that innervate the pharynx are tested together? A. IX and X B. V and VI C. VII and XII D. III and VIII

A. IX and X Rationale Cranial nerves IX and X (glossopharyngeal and the vagus nerve) are tested together because both innervate the pharynx. Cranial nerve V (the trigeminal nerve) has ophthalmic, maxillary, and mandible branches. Cranial nerve VI (abducens) is a motor nerve for an eye muscle. Cranial nerve VII (the facial cranial nerve) innervates cheek muscles and is responsible for taste in the anterior two-thirds of the tongue. Cranial nerve XII (the hypoglossal cranial nerve) is responsible for the motor muscles of the tongue. Cranial nerve III (oculomotor) innervates the eyes and is responsible for eye movement and smooth muscle eye movement. Cranial nerve VIII (the vestibulocochlear nerve) has vestibular and cochlear nerve branches. p. 1305

The nurse is caring for a patient with a neurologic disease that affects the pyramidal tract. What assessment finding is the nurse likely to observe? A. Impaired muscle movement B. Decreased deep tendon reflexes C. Decreased level of consciousness (LOC) D. Impaired sensation of touch, pain, and temperature

A. Impaired muscle movement Rationale Among the most important descending tracts are the corticobulbar and corticospinal tracts, collectively termed the pyramidal tract. These tracts carry volitional (voluntary) impulses from the cortex to the cranial and peripheral nerves. Dysfunction of the pyramidal tract is likely to manifest as impaired movement, because of hypertonicity. Diseases affecting the pyramidal tract do not result in changes in LOC, impaired reflexes, or decreased sensation. p. 1296

During recovery from a lumbar puncture, the patient reports a severe headache. What is the most appropriate action for the nurse to take? A. Increasing the patient's fluid intake B. Checking the patient for urine retention C. Placing the patient in a side-lying position D. Placing cool packs over the patient's lumbar puncture site

A. Increasing the patient's fluid intake Rationale A headache after a lumbar puncture is usually caused by leakage or loss of cerebral spinal fluid ( CSF). Increased fluid intake, either IV or oral as tolerated, will help restore CSF volume. The patient should be encouraged to lie flat for four to six hours. A persistent headache may indicate a CSF leak. Checking for urine retention and placing cool packs over the puncture site are incorrect and inappropriate interventions to treat a severe headache after a lumbar puncture. p. 1309

The nurse observes that a patient's eye jerks while looking to the left. What could be the reason for this symptom? Select all that apply. A. Lesions in the brainstem B. Lesions in the cerebellum C. Upper motor neuron lesions D. Lower motor neuron lesions E. Disorders of the basal ganglia

A. Lesions in the brainstem B. Lesions in the cerebellum Rationale Nystagmus is a jerking or bobbing of the eyes as they track a moving object. Nystagmus can be caused because of lesions in the cerebellum, brainstem, or vestibular system. Antiseizure medications and sedatives can also cause nystagmus. Upper motor neuron lesions, lower motor neuron lesions, and disorders of the basal ganglia are not associated with this symptom. Upper motor neuron lesions may cause upgoing toes with plantar stimulation. Lower motor neuron lesions result in a diminished or absent motor response. Disorders of the basal ganglia may lead to impairment of voluntary movement, resulting in fragmentary or incomplete movements. p. 1297

A patient is suspected to have a spinal lesion. What diagnostic test will the nurse prepare the patient for? A. Myelogram B. Transcranial Doppler C. Cerebral angiography D. Carotid duplex studies

A. Myelogram Rationale Myelogram is a radiation technique that helps detect spinal lesions in patients. Transcranial Doppler is an ultrasound examination that helps to evaluate the velocity of blood flow in blood vessels. Cerebral angiography is a radiation technique that examines intracranial and extracranial blood vessels. Cerebral angiography helps detect tumors and vascular lesions in the brain as well. A carotid duplex study is an ultrasound technique that determines the velocity of blood flow in the veins and arteries. p. 1311

Which cells of the nervous system are characterized by excitability, conductivity, and influence? A. Neurons B. Microglia C. Ependymal cells D. Oligodendrocytes

A. Neurons Rationale Neurons have characteristic features of excitability, conductivity, and influence. Microglia is the specialized macrophage that protects neurons by phagocytosis. Ependymal cells aid in secretion of cerebrospinal fluid. Oligodendrocytes produce the myelin sheath of nerve fibers and provide support to axons in the central nervous system. p. 1294

A patient has hemianopsia from a brain lesion. Which cranial nerve does the nurse determine is affected in this patient? A. Optic nerve B. Olfactory nerve C. Oculomotor nerve D. Vestibulocochlear nerve

A. Optic nerve Rationale A change in one-half of the visual field resulting from brain lesions is referred to as hemianopsia. Visual fields and acuity assessment will determine the function of the optic nerve. Examination of the olfactory nerve will determine the sense of smell. Examination of the oculomotor nerve will help to assess the movement of the eye. Examination of vestibulocochlear nerve will help assess hearing. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation. p. 1305

Which lobe of the cerebrum helps integrate somatic and sensory input? A. Parietal lobe B. Anterior frontal lobe C. Anterior temporal lobe D. Posterior temporal lobe

A. Parietal lobe Rationale The parietal lobe of the brain helps in integrating the somatic and sensory input. The anterior frontal lobe controls higher-order processes, such as judgment and reasoning. The anterior temporal lobe integrates past experiences. The posterior temporal lobe helps in integrating visual and auditory input for language. p. 1339

Which patient is susceptible to Parkinson's disease, according to the medical records of four patients that the nurse reviews? A. Patient A: Deficiency of dopamine B. Patient B: Cauda equine C. Patient C: Intracranial injury D. Patient D: Acute hemorrhage

A. Patient A: Deficiency of dopamine Rationale Parkinson's disease is a progressive disease of the nervous system. Dopamine plays an important role in controlling neuron function. Destruction of dopamine-secreting neurons causes dopamine deficiency, which may result in Parkinson's disease in Patient A. Compression of the nerve root causes cauda equine, as seen in Patient B. Intracranial injury puts Patient C at risk for increased intracranial pressure (ICP). Acute hemorrhage causes the expansion of brain tissue in Patient D. p. 1337

The nurse is performing a physical assessment on a patient. Which tests are used to assess the sensory system? Select all that apply. A. Position sense B. Intact gag reflex C. Finger-nose test D. Intact swallow reflex E. Intact sensation to light touch

A. Position sense B. Intact gag reflex E. Intact sensation to light touch Rationale Position sense, intact sensation to light touch, and gag reflex all help in the assessment of the sensory system. The gag reflex and swallow reflex are important in the assessment of cranial nerves. The finger-nose test helps in assessment of motor system. Test-Taking Tip: Practicing a few relaxation techniques may prove helpful on the day of an examination. Relaxation techniques such as deep breathing, imagery, head rolling, shoulder shrugging, rotating and stretching of the neck, leg lifts, and heel lifts with feet flat on the floor can effectively reduce tension while causing little or no distraction to those around you. It is recommended that you practice one or two of these techniques intermittently to avoid becoming tense. The more anxious and tense you become, the longer it will take you to relax. p. 1307

The nurse performs a fall risk assessment for an older adult patient. Which normal nervous system changes of aging does the nurse determines places this patient at a higher risk of falls? Select all that apply. A. Sensory deficit B. Memory deficit C. Motor function deficit D. Cranial and spinal nerves E. Reticular activation system F. Central nervous system changes

A. Sensory deficit C. Motor function deficit F. Central nervous system changes Rationale An older person is at a higher risk for falls because the changes in the nervous system decrease the sensory function, which leads to poor ability to maintain balance and a widened gait. The motor function deficit decreases muscle strength and agility. The central nervous system changes in the brain lead to a diminished kinesthetic or position sense. Memory deficits, normal changes of cranial and spinal nerves, and the reticular activation system do not contribute to the increased risk of falls. p. 1302

The nurse is providing care to a patient who is experiencing alterations in mood, sleep, and emotions. Which neurotransmitter may be responsible for the patient's clinical manifestations? A. Serotonin B. Acetylcholine C. Norepinephrine D. γ-aminobutyric acid

A. Serotonin Rationale Serotonin is an important neurotransmitter in the central nervous system involved in the regulation of mood, sleep, and emotions. The patient's symptoms may be caused by a lack of this neurotransmitter. Acetylcholine acts on cholinergic receptors. A decrease in acetylcholine results in neurologic conditions such as Alzheimer's disease. Norepinephrine is a hormone and neurotransmitter involved in the flight-or-fight response and increasing the heart rate and blood flow to the skeletal muscles. The chief inhibitory neurotransmitter in the central nervous system is γ-aminobutyric acid. It has a role in the regulation of neuronal excitability throughout the nervous system. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. p. 1295

When performing an assessment of the neurologic system, how should the nurse assess the most basic sense of touch? Select all that apply. A. Touching the skin with a light pin prick B. Using a cotton wisp to touch the extremities C. Applying tubes of warm and cold water to the skin D. Applying a vibrating tuning fork to the fingernails E. Simultaneously touching both sides of the body symmetrically

A. Touching the skin with a light pin prick B. Using a cotton wisp to touch the extremities E. Simultaneously touching both sides of the body symmetrically Rationale The sense of touch can be assessed by using a cotton wisp to touch the extremities and by touching the skin with a light pinprick. The patient is then asked whether he or she can feel the stimulus. The sensation of extinction is assessed by simultaneously touching both sides of the body symmetrically and noting if the patient feels both sides. The sensation of temperature can be tested by applying tubes of warm and cold water to the skin and asking the patient to identify the stimuli with the eyes closed. The sense of vibration is assessed by applying a vibrating tuning fork to the fingernails. p. 1306

A nurse elicits the gag reflex in a patient. Which cranial nerve is the nurse assessing with this technique? Select all that apply. A. Vagus nerve B. Facial nerve C. Olfactory nerve D. Trochlear nerve E. Glossopharyngeal nerve

A. Vagus nerve E. Glossopharyngeal nerve Rationale The gag reflex tests the performance of the motor component of the vagus nerve and the sensory component of the glossopharyngeal nerve. The test is performed by touching the sides of the posterior pharynx or soft palate with a tongue blade. The olfactory nerve is assessed by asking the patient to close each nostril one at a time and identify easily recognized odors. The facial nerve is assessed by asking the patient to raise the eyebrows, close the eyes tightly, purse the lips, draw back the corners of the mouth in an exaggerated smile, and frown. The trochlear nerve is assessed along with oculomotor and abducens nerves, because all three nerves help move the eyes. Test-Taking Tip: When using this program, be sure to note if you guess at an answer. This will permit you to identify areas that need further review. Also it will help you to see how correct your guessing can be. p. 1305

The nurse provides information to a student nurse about neurotransmitters. Which statement made by the student nurse indicates the need for further teaching? A. "Epinephrine is both a hormone and neurotransmitter." B. "Enkephalins deficiency causes amyotrophic lateral sclerosis." C. "Norepinephrine triggers the release of glucose from energy stores." D. "γ-aminobutyric acid regulates neuronal excitability throughout the nervous system."

B. "Enkephalins deficiency causes amyotrophic lateral sclerosis." Rationale Glutamate deficiency causes amyotrophic lateral sclerosis (ALS). Enkephalins function as neurotransmitters or neuromodulators at many locations in the brain and spinal cord and are involved with pain perception. Epinephrine acts both as a hormone and a neurotransmitter and plays an important role in the fight-or-flight response. Norepinephrine triggers the release of glucose from energy stores. γ-aminobutyric acid maintains neuronal excitability throughout the nervous system. p. 1295

A nurse taps the triceps tendon just above the olecranon process in a patient with the elbow flexed and the forearm resting across the patient's chest. Which reactions indicate a normal response? Select all that apply. A. Flexion of the arm B. Extension of the arm C. Relaxation of triceps muscle D. Contraction of triceps muscle E. Continued rhythmic contraction of the muscle

B. Extension of the arm D. Contraction of triceps muscle Rationale The triceps reflex is elicited by striking the triceps tendon above the elbow while the patient's arm is flexed. The normal response is extension of the arm or visible contraction of the triceps. Clonus is an abnormal response characterized by a continued rhythmic contraction of the muscle with continuous application of the stimulus. Flexion of the arm and relaxation of the triceps muscle when eliciting the triceps reflex are abnormal responses and indicate a dysfunctional neurologic system. p. 1307

The nurse is assessing the patient's accessory nerve. Which instructions should the nurse give to the patient? Select all that apply. A. "Protrude your tongue." B. "Shrug your shoulders." C. "Close your eyes tightly." D. "Read the Snellen chart." E. "Turn your head against resistance to either side."

B. "Shrug your shoulders." E. "Turn your head against resistance to either side." Rationale The accessory nerve controls the sternocleidomastoid and trapezius muscles that aid in head rotation, shoulder elevation, and abduction of the arm. Therefore while assessing the patient's accessory nerve, the nurse should ask the patient to shrug the shoulders and turn the head to either side against resistance. The nurse should ask the patient to protrude the tongue while assessing olfactory nerve function. The nurse should ask the patient to read the Snellen chart to assess optic nerve function. The nurse should ask the patient to close the eyes tightly while assessing facial nerve function. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 1305

Which part of the central nervous system carries specific sensory information to higher levels of the central nervous system? A. Reflex arc B. Ascending tracts C. Descending tracts D. Lower motor neurons

B. Ascending tracts Rationale The ascending tracts carry specific sensory information to higher levels of the central nervous system. The reflex arc in the spinal cord plays an important role in maintaining muscle tone. Descending tracts carry impulses that are responsible for muscle movement. Descending motor tracts influence the skeletal muscle through lower motor neurons. p. 1296

The nurse is performing an assessment of the accessory nerve. What should the nurse ask the patient to do? A. Assess the gag reflex by stroking the posterior pharynx. B. Ask the patient to shrug the shoulders against resistance. C. Ask the patient to push the tongue to either side against resistance. D. Have the patient say "ah" while visualizing elevation of the soft palate.

B. Ask the patient to shrug the shoulders against resistance. Rationale The spinal accessory nerve is tested by asking the patient to shrug the shoulders against resistance and to turn the head to either side against resistance while observing the sternocleidomastoid muscles and the trapezius muscles. Assessing the gag reflex and saying "ah" are used to assess the glossopharyngeal and vagus nerves. Asking the patient to push the tongue to either side against resistance and to stick out the tongue are used to assess the hypoglossal nerve. p. 1305

Which cells help in restoring the neurochemical milieu after brain injury? A. Schwann cells B. Astrocyte cells C. Presynaptic cell D. Ependymal cells

B. Astrocyte cells Rationale Astrocyte cells help in restoring the neurochemical milieu after brain injury. They also act as phagocytes for neuronal debris and provide support for repair. Schwann cells myelinate the nerve fibers in the periphery. Ependymal cells line the brain ventricles and aid in the secretion of cerebrospinal fluid. Presynaptic cells release an excitatory neurotransmitter. p. 1294

A patient has gliosis in the central nervous system (CNS). Which glial cell could be the reason for this condition in the patient? A. Microglia B. Astrocytes C. Schwann cells D. Ependymal cells

B. Astrocytes Rationale Gliosis, a proliferation of astrocytes, leads to formation of a glial scar in the CNS. Microglia plays an important role in inflammation during brain injury. Ependymal malfunction leads to disturbances of cerebral spinal fluid flow and risk for hydrocephaly. Improper functioning of Schwann cells causes loss of myelin, resulting in demyelinating diseases. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. p. 1295

The nurse reviews a diagnostic test report for a patient with a brain injury which shows neuronal debris and alteration of neurochemical milieu. Which type of nerve cell works to restore normal condition? A. Microglia B. Astrocytes C. Ependymal cells D. Oligodendrocytes

B. Astrocytes Rationale When the brain is injured, astrocytes act as phagocytes for neuronal debris and help restore neurochemical milieu. Microglia plays an important role in inflammation in brain injury. Ependymal cells line the brain ventricles and aid in the secretion of cerebrospinal fluid. Oligodendrocytes are specialized cells that produce the myelin sheath of nerve fibers in the central nervous system. p. 1295

The nurse documents "PERRLA, EOMs intact" after performing an assessment. The nurse knows this indicates integrity of which cranial nerves? Select all that apply. A. CN II (optic) B. CN III (oculomotor) C. CN IV (trochlear) D. CN V (trigeminal) E. CN VI (abducens) F. CN VII (facial)

B. CN III (oculomotor) C. CN IV (trochlear) E. CN VI (abducens) Rationale Cranial nerve III (oculomotor), cranial nerve IV (trochlear), and cranial nerve VI (abducens) help move the eye and are tested together. The oculomotor nerve controls the movement of the pupil and is reflected in the documentation PERRLA (pupils equal, round, react to light, and accommodation). The trochlear and abducens nerves control the movement of the eye into the six cardinal gazes reflected in the extraocular movements (EOMs). The optic nerve, cranial nerve II, is assessed through checking visual acuity. The facial nerve, cranial nerve VII, has a sensory and motor branch and is assessed through raising the eyebrows, smiling, frowning, pursing lips, and through interpretation of sweet and salty taste on the anterior two-thirds of the tongue. p. 1306

The nurse is assessing the innervation of the lateral rectus of the eye. Which cranial nerve will the nurse assess? A. CN I B. CN VI C. CN VIII D. CN IX

B. CN VI Rationale The abducens is the sixth cranial nerve, which innervates the lateral rectus of the eye. The trochlear nerve innervates the superior oblique muscle. The accessory nerve innervates the sternocleidomastoid and trapezius muscles. The oculomotor nerve innervates the levator palpebrae muscle. Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question. p. 1305

The nurse is obtaining a health history from a patient reporting memory loss and dizziness. With which neurologic component does the nurse document that these findings correlate? A. Activity exercise B. Cognitive perceptual C. Self-perception self-concept D. Health perception-health management

B. Cognitive perceptual Rationale A patient's subjective report of memory loss and dizziness belongs to the cognitive perceptual assessment portion of a health history. Activity exercise is an assessment of the patient's physical coordination and activity. Health perception-health management includes assessment of a patient's health history and habits. Assessment of the patient's self-perception self-concept explores the patient's emotional state. p. 1303

A nurse tests the bicep reflex in a patient. What reaction does the nurse document as a normal response? Select all that apply. A. Relaxation of biceps muscle B. Contraction of biceps muscle C. Flexion of the arm at the elbow D. Extension of the arm at the elbow E. Continued rhythmic contraction of the muscle

B. Contraction of biceps muscle C. Flexion of the arm at the elbow Rationale The bicep reflex is elicited with the patient's arm partially flexed and palm up, by placing the nurses' thumb over the biceps tendon in the antecubital space and striking the thumb with a hammer. The normal response is flexion of the arm at the elbow or contraction of the biceps muscle that can be felt by the thumb. Clonus is an abnormal response characterized by a continued rhythmic contraction of the muscle with continuous application of the stimulus. Extension of the arm at the elbow and relaxation of the biceps muscle on the biceps test are abnormal responses and indicate a dysfunctional neurologic system. Test-Taking Tip: Avoid spending excessive time on any one question. Most questions can be answered in one to two minutes. p. 1307

A patient with a suspected spinal cord infection is admitted to the hospital. What diagnostic tests should the nurse anticipate for the patient? Select all that apply. A. Evoked potentials B. Cranial myelogram C. Carotid duplex studies D. Computed tomography E. Measurement of cerebrospinal fluid pressure

B. Cranial myelogram E. Measurement of cerebrospinal fluid pressure Rationale A myelogram and measurement of the cerebrospinal fluid are important for a patient with spinal cord infection. A myelogram is an x-ray of the spinal cord and vertebral column. The analysis of cerebrospinal fluid provides useful diagnostic information related to nervous system diseases. Increased intracranial pressure, indicated by increased cerebrospinal fluid pressure, can force downward herniation of the brain and brainstem. Evoked potentials refer to the electrical activity associated with nerve conduction along the sensory pathways. Carotid duplex studies combine ultrasound and pulsed Doppler technology. These are used to indicate when there is stenosis of a vessel. A computed tomography scan is a computer-assisted x-ray of multiple cross sections of the body used to detect problems such as hemorrhage, tumors, cysts, edema, infarctions, brain atrophy, and other abnormalities. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. p. 1311

The nurse is caring for a patient with altered function of the lungs and digestive system. Which cranial nerve should the nurse assess? A. Cranial nerve IX B. Cranial nerve X C. Cranial nerve XI D. Cranial nerve XII

B. Cranial nerve X Rationale Cranial nerves emerge from the brain and exchange information between the brain and parts of the body. Cranial nerve X, the vagal nerve, transfers information from the heart, lungs, and the digestive system. Cranial nerve IX, the glossopharyngeal nerve, transports nervous stimulations from the pharynx and tongue to the brain. Cranial nerve XI, the accessory nerve, supports motor function to the sternocleidomastoid and trapezius muscles. Cranial nerve XII, the hypoglossal nerve, controls the extrinsic muscles of the tongue. p. 1305

A patient demonstrates a lack of coordination in articulating speech. What could be the cause of this symptom? Select all that apply. A. Optic nerve injury B. Cranial nerve lesion C. Antiseizure medications D. Lesions in the spinal cord E. Lesions in the parietal cortex

B. Cranial nerve lesion C. Antiseizure medications Rationale Lack of coordination in articulating speech is called dysarthria. Cranial nerve lesions may be responsible for this because of their association with the regulation of speech. Slurred speech can also be a side effect of the long-term use of antiseizure medications. The spinal cord, parietal cortex, and optic nerve are not associated with speech regulation. Test-Taking Tip: Make educated guesses when necessary. p. 1305

Which part of the spinal cord carries impulses for muscle movement? A. Ascending tract B. Descending tract C. Lower motor neurons D. Upper motor neurons

B. Descending tract Rationale The descending tract carries impulses that are responsible for muscle movement. The ascending tracts carry specific sensory information to higher levels of the central nervous system. Lower motor neurons and upper motor neurons influence the skeletal muscle movement. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response. p. 1296

The nurse asks the patient to close their eyes and then places the two points of a measuring caliper 1 inch apart on the patient's lower forearm. The nurse asks the patient to identify the sensation. What is the nurse assessing? A. Stereognosis B. Discrimination C. Graphesthesia D. Proprioception

B. Discrimination Rationale The nurse is assessing gross two-point discrimination, or the ability of the patient to sense two distinct pressure points. To be most diagnostic, the nurse will move the two points closer together until the patient can no longer distinguish two separate pressure points and the distance is measured. This test aids in diagnosing sensory cortex and peripheral nervous system disorders. Graphesthesia tests the ability to feel writing on the skin. Stereognosis is the ability to perceive the form and nature of an object. Proprioception is when position sense is assessed by moving a body part and asking the patient to identify position. p. 1307

What is the result of lesions involving motor pathways of cranial nerves IX and X? A. Apraxia B. Dysphagia C. Analgesia D. Atonic bladder

B. Dysphagia Rationale Lesions involving motor pathways of cranial nerves IX and X result in dysphagia. Analgesia is a loss of pain sensation as a result of lesions in the spinothalamic tract or thalamus. Analgesic drugs can also cause a loss of pain sensation. An atonic bladder occurs in the early stages of a spinal cord injury. Apraxia occurs in the presence of a cerebral cortex brain lesion and is characterized by the inability to perform learned movements. p. 1309

The nurse is caring for a patient with a neurologic disorder. What findings should be taken into consideration during a cranial nerve assessment in a patient? Select all that apply. A. Normal tandem walk B. Facial movements full C. Pupils reactive to light D. Midline protrusion of tongue E. Downgoing toes with plantar stimulation

B. Facial movements full C. Pupils reactive to light D. Midline protrusion of tongue Rationale Pupils that are equally reactive to light suggest normal functioning of the oculomotor nerve. Midline protrusion of the tongue suggests normal functioning of the hypoglossal nerve. Full facial movements indicate normal functioning of the facial nerve. A normal tandem walk is associated with the motor system, and downgoing toes with plantar stimulation is associated with reflexes. pp. 1307-1308

Which cells constitute almost half of the brain and spinal cord mass? A. Neurons B. Glial cells C. Schwann cells D. Neurotransmitters

B. Glial cells Rationale Glial cells provide support, protection, and nourishment to neurons and constitute almost half the brain and spinal cord mass. Schwann cells myelinate the nerve fibers in the periphery. Neurotransmitters are chemicals that affect the transmission of impulses across the synaptic cleft. Neurons are one of the two types of cells that make up the nervous system and are supportive of glial cells. p. 1294

A patient is diagnosed with an upper motor neuron (UMN) lesion. What assessment finding does the nurse anticipate observing? A. Areflexia B. Hyperreflexia C. Denervation atrophy D. Decreased muscle tone

B. Hyperreflexia Rationale Hyperreflexia is associated with upper motor neuron (UMN) lesions. Areflexia or hyporeflexia, denervation atrophy, and decreased muscle tone are associated with lower motor neuron (LMN) lesions. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers p. 1297

A patient is unable to recognize the form of an object by touch. What could be the cause of this disorder? A. Lesions in the brainstem B. Lesions in the parietal cortex C. Lesions on the cranial nerves D. Lesions in the left cerebral cortex

B. Lesions in the parietal cortex Rationale The inability to recognize an object by touch is known as astereognosis. The parietal cortex plays an important role in producing planned movements, and lesions in the parietal cortex result in astereognosis. Lesions on the cranial nerves cause visual disturbances, both sensory and motor, as well as dysarthria and a lack of coordination in articulating speech. Left cerebral cortex lesions cause aphasia or dysphasia. Lesions in the brainstem result in ophthalmoplegia, paralysis of the eye muscle. p. 1307

A patient is suspected of having a lesion involving the subarachnoid space. What problems associated with this lesion does the nurse suspect the patient will have? A. Function of blood-brain barrier B. Movement of cerebral spinal fluid C. Production of cerebral spinal fluid (CSF) D. Communication between cerebral hemispheres

B. Movement of cerebral spinal fluid Rationale CSF bathes the brain and spinal cord by traveling along the subarachnoid space. A lesion in this area can interfere with movement of CSF through this space. CSF is produced in the pia mater, which is also the location of the blood brain barrier. The inner layer of the dura mater dips between the two hemispheres to form the tentorium, which aids in communication of impulses between the two hemispheres. p. 1300

Which is the primary functional unit of the nervous system? A. Axon B. Neuron C. Dendrite D. Myelin sheath

B. Neuron Rationale Neurons are the primary functional unit of the nervous system. The myelin sheath is a white lipid protein substance that acts as an insulator for the conduction of impulses. Axons carry nerve impulses to other neurons or to end organs such as smooth and striated muscles and glands. Dendrites are short processes extending from the cell body that receive impulses or signals from other neurons and conduct them toward the cell body. p. 1294

What is the location of the visual area in the cerebrum? A. Parietal lobe B. Occipital lobe C. Anterior temporal lobe D. Posterior temporal lobe

B. Occipital lobe Rationale The visual area is located in the occipital lobe of the cerebrum and it registers visual images. The parietal lobe consists of association areas that integrate somatic and sensory output. The anterior temporal lobe has association areas, which integrate past experiences. The posterior temporal lobe consists of association areas that integrate visual and auditory input for language comprehension. p. 1296

A patient reports having blurred vision. Which cerebral lobe can cause blurred vision because of the presence of lesions? Select all that apply. A. Frontal B. Parietal C. Occipital D. Temporal E. Postcentral gyrus

B. Parietal C. Occipital D. Temporal Rationale Visual field defects may arise from lesions of the optic nerve, optic chiasma, or tracts that extend through the temporal, parietal, or occipital lobes, because they are responsible for visual field and acuity. The frontal lobe is responsible for higher-order processes such as judgment and reasoning. The postcentral gyrus is responsible for sensory response from the opposite side of body. p. 1306

Which patient is likely to have an inability to sense taste, as identified by the nurse during assessment of a group of four patients? A. Patient A: Damaged optic nerve B. Patient B: Damaged facial nerve C. Patient C: Damaged olfactory D. Patient D: Damaged oculomotor nerve

B. Patient B: Damaged facial nerve Rationale The facial nerve innervates the facial and cheek muscles and regulates the taste in the anterior two-thirds of the tongue. Damage to the nerve, which Patient B has, can result in an inability to sense taste. Patient A has a damaged optic nerve, and the optic nerve transmits visual information from the retina of eyes to the vision centers of the brain. Patient C has a damaged olfactory nerve, which transmits impulses that convey the sense of smell. Patient D has a damaged oculomotor nerve, which controls eye movements. p. 1305

The nurse is caring for an older adult patient with diminished hearing and visual loss. What type of age-related finding does the nurse determine the patient has developed? A. Sensory change B. Perceptual confusion C. Decreased nerve conduction D. Decreased neurotransmitters

B. Perceptual confusion Rationale The geriatric patient who has reduced hearing and vision are experiencing perceptual confusion. Decreased taste and smell perception are considered sensory changes. Changes in the myelin of the peripheral nervous system result in decreased nerve conduction, which may alter the coordination of neuromuscular activity. Decreased neurotransmitters affect the transmission of impulses and are responsible for a slowed response time. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options . p. 1301

The nurse suspects that a patient has a damaged accessory nerve. What function is the patient likely to be unable to perform during assessment when requested? A. Hear sounds B. Raise the hand C. Identify the tastes of food D. Identify the smell of flowers

B. Raise the hand Rationale Sternocleidomastoid and trapezius muscles play an important role in hand movement. The accessory nerve controls the function of the sternocleidomastoid and trapezius muscles and an inability to raise the hands indicates damage to the accessory nerve. Hearing impairment indicates damage to the vestibulocochlear nerve. An inability to identify the tastes indicates damage to the facial nerve. An inability to identify smells indicates damage to the olfactory nerve. p. 1305

A nurse is caring for a patient with a suspected accessory nerve injury. What instructions will the nurse give to the patient to test the functions of this nerve? Select all that apply. A. Elicit gag reflex B. Shrug the shoulders C. Turn the head to either side against resistance D. Ask the patient to move the tongue up and down and side to side E. Ask the patient to push the tongue to either side against resistance

B. Shrug the shoulders C. Turn the head to either side against resistance Rationale The accessory nerve controls the functions of the sternocleidomastoid and trapezius muscles. It is tested by asking the patient to shrug the shoulders and turn the head to either side against resistance. There should be smooth contraction of the sternocleidomastoid and trapezius muscles. The gag reflex is elicited to test the glossopharyngeal and vagus nerves. When testing the hypoglossal nerve, the patient is asked to move the tongue up and down and side to side and to push the tongue to either side against resistance. p. 1305

What portion of the ascending spinal cord tract carries information regarding pain and temperature sensation? A. Pyramidal tracts B. Spinothalamic tracts C. Spinocerebellar tracts D. Dorsal (posterior) columns

B. Spinothalamic tracts Rationale The spinothalamic tracts are ascending spinal cord tracts that carry pain and temperature sensation to the thalamus. The spinocerebellar tracts carry information about muscle tension and body position to the cerebellum. The dorsal columns carry information about touch, deep pressure, vibration, position sense, and kinesthesia. The pyramidal tracts are descending tracts that carry voluntary impulses from the extrapyramidal system. The extrapyramidal system is concerned with voluntary movement. p. 1296

The nurse is attempting to elicit the brachioradialis reflex in a patient during a neurologic assessment. What technique will the nurse use that will be most effective? A. Strike the patellar tendon just above the patella while the patient is sitting. B. Strike the radius 3 to 5 cm above the wrist while the patient's arm is relaxed. C. Strike the thumb with a hammer after placing the thumb over the triceps tendon in the antecubital space. D. Strike the Achilles tendon while the patient's leg is flexed at the knee and the foot is in a position of plantar flexion.

B. Strike the radius 3 to 5 cm above the wrist while the patient's arm is relaxed. Rationale While eliciting the brachioradialis reflex, the nurse should strike the radius 3 to 5 cm above the wrist while the patient's arm is relaxed. While eliciting the patellar reflex, the nurse should strike the patellar tendon just below the patella while the patient is in a sitting position. While eliciting the biceps reflex, the nurse should strike the thumb with a hammer by placing the thumb over the biceps tendon in the antecubital space. While eliciting the Achilles tendon reflex, the nurse strikes the Achilles tendon while the patient's leg is flexed at the knee and the foot is gently dorsiflexed. p. 1307

What is the function of spinocerebellar tracts? A. To carry volitional impulses B. To carry information about muscle tension C. To carry pain and temperature sensations D. To carry impulses concerned with deep pressure

B. To carry information about muscle tension Rationale The spinocerebellar tracts carry information about muscle tension to the cerebellum to coordinate movement. The pyramidal tracts carry the volitional impulses. The spinothalamic tracts carry pain and temperature sensations. The posterior column carries impulses concerned with deep pressure. p. 1299

When performing a physical examination on a patient with a suspected motor system disorder, what manifestations is the nurse likely to find? Select all that apply. A. Nystagmus B. Unsteady gait C. Asymmetric smile D. Positive Romberg test E. Full facial movements F. Inability to perform finger-nose test

B. Unsteady gait D. Positive Romberg test F. Inability to perform finger-nose test Rationale During assessment of the motor system, findings such as a normal gait and station, a negative Romberg test, and a smooth performance of the finger-nose test are essential to confirm normal functioning of the motor nerves. An asymmetric smile, full facial movements, and nystagmus are associated with assessment of the cranial nerves. p. 1306

A patient with a lesion in the central nervous system has developed spasticity with hyperreflexia, weakness, paralysis in the lower extremities, and disuse atrophy. Where does the nurse suspect this lesion may be located according to the clinical manifestations? A. Reflex arcs B. Upper motor neurons C. Lower motor neurons D. Ventral roots of the spinal nerves

B. Upper motor neurons Rationale Upper motor neurons influence skeletal muscle movement. Upper motor neuron lesions generally cause weakness or paralysis, disuse atrophy, hyperreflexia, and spasticity. Reflex arcs play an important role in maintaining muscle tone. The motor output exits the spinal cord by way of the ventral roots of the spinal nerves. Descending tract lower motor neuron lesions generally cause weakness or paralysis, denervation atrophy, hyporeflexia or areflexia, and decreased muscle tone (flaccidity). Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. p. 1296

When performing a cranial nerve assessment on a patient, the nurse tickles the back of the pharynx and notes the contraction of the surrounding muscles. This procedure helps in testing the function of which nerves? Select all that apply. A. Facial nerve B. Vagus nerve C. Accessory nerve D. Hypoglossal nerve E. Glossopharyngeal nerve

B. Vagus nerve E. Glossopharyngeal nerve Rationale Stimulating the pharynx helps to assess the glossopharyngeal and vagus nerves; these nerves are tested together because both stimulate the pharynx. The hypoglossal nerve is tested by asking the patient to protrude the tongue. The facial nerve is tested by asking the patient to raise the eyebrows, close the eyes tightly, purse the lips, draw back the corners of the mouth in an exaggerated smile, and frown. The accessory nerve is tested by asking the patient to shrug the shoulders and turn the head to either side against resistance. p. 1305

The assessment of temperature sensation occurs in which situation? A. With the pronator drift test B. When the pain reflex is absent C. With the extinction assessment D. During a sensory system assessment

B. When the pain reflex is absent Rationale In the absence of pain, temperature sensation is assessed. If the pain sensation is intact, the assessment of temperature sensation may be omitted, because the same ascending pathways carry both sensations. The pronator drift test is a motor systems test. Extinction is an assessment that occurs by simultaneously touching both sides of the body symmetrically to assess for the perception of symmetrical sensation. A sensory system assessment does include a pain assessment. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers. p. 1306

The nurse is demonstrating neurologic assessment techniques to a student nurse for an older adult patient. What statement by the student nurse demonstrates further instruction is required? A. "Diminished strength and agility occur due to decreased muscle bulk." B. "Assessment of deep tendon reflexes reveals an average reflex score." C. "Decreased oxygen supply results in a decreased risk of postural hypotension." D. "Disturbances of sleep pattern occur due to modification of hypothalamic function."

C. "Decreased oxygen supply results in a decreased risk of postural hypotension." Rationale In older patients, a decreased blood flow rate can cause decreased oxygen supply to the brain, resulting in increased postural hypotension during change of position. In older patients, an assessment of deep tendon reflexes usually reveals an average reflex score. Diminished strength and agility occurs due to decreased muscle bulk in older patients. Disturbances of sleep pattern occur in older patients due to modification of hypothalamic function. p. 1302

The nurse is conducting an assessment to determine if a patient with a history of psychosis has a new cognitive problem. What characteristics should the nurse assess? Select all that apply. A. Ability to eat and drink B. Ability to button a shirt C. Ability to add and subtract D. Ability to remember five objects E. Ability to repeat several sentences F. Ability to control bowel and bladder

C. Ability to add and subtract D. Ability to remember five objects E. Ability to repeat several sentences Rationale A patient with a cognitive problem may have problems remembering five objects, repeating several sentences, and adding and subtracting. Ability to eat and drink, continence, and buttoning a shirt are motor abilities, not cognitive abilities. p. 1303

Which neurotransmitter is released by the preganglionic and postganglionic fibers during the parasympathetic response? A. Dopamine B. Epinephrine C. Acetylcholine D. Norepinephrine

C. Acetylcholine Rationale The preganglionic and postganglionic fibers release acetylcholine during a parasympathetic response. The major neurotransmitter released by the postganglionic fibers of the sympathetic nervous system is norepinephrine. Dopamine is an inhibitory neurotransmitter that activates postsynaptic receptors to increase the likelihood that an action potential will be generated. Epinephrine is released by the adrenal glands and is an excitatory neurotransmitter. p. 1299

How should the nurse most accurately assess the position sense of a patient with a recent traumatic brain injury? A. Ask the patient to close his or her eyes and slowly bring the tips of the index fingers together. B. Ask the patient to close his or her eyes and identify the presence of a common object on the forearm. C. Ask the patient to stand with the feet together and eyes closed and observe for balance maintenance. D. Place the two points of a calibrated compass on the tips of the fingers and toes and ask the patient to discriminate the points.

C. Ask the patient to stand with the feet together and eyes closed and observe for balance maintenance. Rationale The Romberg test is an assessment of position sense in which the patient stands with the feet together and then closes his or her eyes while attempting to maintain balance. Asking the patient to close his or her eyes and slowly bring the tips of the index fingers together, asking the patient to close his or her eyes and identify the presence of a common object on the forearm, or placing the two points of a calibrated compass on the tips of the fingers and toes and asking the patient to discriminate the points do not directly assess position sense. p. 1307

A patient's sudden onset of hemiplegia has necessitated a computed tomography (CT) of the head. Which assessment should the nurse complete before this diagnostic study? A. Assess the patient's immunization history. B. Screen the patient for any metal parts or a pacemaker. C. Assess the patient for allergies to shellfish, iodine, or dyes. D. Assess the patient's need for tranquilizers or antiseizure medications.

C. Assess the patient for allergies to shellfish, iodine, or dyes. Rationale Allergies to shellfish, iodine, or dyes contraindicate the use of contrast media in CT. The patient's immunization history is not a central consideration, and the presence of metal in the body does not preclude the use of CT as a diagnostic tool. The need to assess for allergies supersedes the need for tranquilizers or antiseizure medications in the majority of patients. p. 1310

Which component of the neurologic system is responsible for blood pressure changes in the older adult patient? A. Motor reflexes B. Central nervous system (CNS) C. Autonomic nervous system (ANS) D. Peripheral nervous system (PNS)

C. Autonomic nervous system (ANS) Rationale Changes in the ANS may result in orthostatic hypotension or systolic hypertension. Changes that occur in the CNS result in many changes in the brain, including altered balance, gait, and the impaired ability to regulate environmental temperature. Motor reflexes decrease resulting in sluggish reflexes and a slowed reaction time. Further changes that occur in the gerontologic patient affect the PNS resulting in a decreased reaction time in certain nerves and decreased speed and intensity of neuronal reflexes. p. 1302

A patient has an inability to speak after experiencing an intracranial injury. Which area of the brain has been affected? A. A: precentral gyrus B. B: angular gyrus C. C: Broca's area D. D: postcentral gyrus

C. C: Broca's area Rationale Damage to Broca's area due to intracranial injury can result in an inability for speech. The part indicated as C in the figure depicts Broca's area, which regulates verbal expression. The part indicated as A in the figure depicts the precentral gyrus, which regulates motor control and movement on the opposite side of the body. The part indicated as B in the figure represents the angular gyrus that helps to process language, numbers, and spatial cognition. The part indicated as D in the figure depicts the postcentral gyrus, which is the receptive area to sense touch. p. 1298

A patient informs the nurse they have difficulty hearing and ask people to repeat themselves constantly. Which cranial nerve (CN) should the nurse assess in this patient? A. CN IV B. CN VI C. CN VIII D. CN X

C. CN VIII Rationale Cranial nerve VIII is the vestibulocochlear nerve. It controls the function of the auditory sensory organ and the cochlea; therefore the nurse should assess the vestibulocochlear nerve. Cranial nerve IV is the trochlear nerve, which controls the function of eye movement. Cranial nerve VI is the abducens nerve, and it controls the function of the lateral rectus of the eye. Cranial nerve X is the vagus nerve, which controls the function of the heart and lungs. p. 1305

The nurse is collaborating with the health care provider in the care of a patient with a suspected neurologic injury. The health care provider wants to assess the integrity of the brain stem. What should the nurse prepare to assist the health care provider with? A. Balance B. Reflexes C. Cranial nerves D. Cerebral spinal fluid

C. Cranial nerves Rationale Cranial nerves exit the cranium via the brain stem. Assessment of cranial nerves gives a baseline of the brain stem integrity and function. Assessment of reflexes assesses the integrity of the reflex arc, which is the sensory message sent to the brain from the periphery and the motor response that follows. The cerebellum controls balance. Examination of cerebral spinal fluid aids in identifying the increase in diseases and conditions of the brain and spinal column, such as malignancy, infection, and problems with production or movement. p. 1297

While performing an assessment of extraocular movements, the nurse notes the eyes do not move together. How will the nurse document this movement? A. Tracking B. Nystagmus C. Disconjugate D. Accommodation

C. Disconjugate Rationale With weakness or paralysis of one of the eye muscles, the eyes do not move together. This is described as disconjugate gaze. Nystagmus is fine, rapid jerking movement of the eyes, particularly with lateral gaze. Accommodation is when pupils constrict with near vision. Tracking is when the eyes follow a moving object in a coordinated fashion. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation. p. 1306

How will the nurse document weakness or paralysis of an eye muscle in the patient causing the eyes to not move together? A. Anosmia B. Nystagmus C. Disconjugate gaze D. Bitemporal hemianopsia

C. Disconjugate gaze Rationale A disconjugate gaze occurs when the eyes do not move together. Anosmia is a loss of sense of smell. When bitemporal hemianopsia occurs, the peripheral vision is affected. Nystagmus is a fine rapid jerking movement of the eyes and is observed with a disconjugate gaze. p. 1306

When performing a physical examination on a healthy patient, how would the nurse test the glossopharyngeal and vagus nerves? Select all that apply. A. Elicit the cough reflex. B. Ask the patient to shrug the shoulders. C. Have the patient phonate by saying "ah." D. Touch the sides of the posterior pharynx with a tongue blade. E. Ask the patient to protrude the tongue to see midline protrusion.

C. Have the patient phonate by saying "ah." D. Touch the sides of the posterior pharynx with a tongue blade. Rationale The vagus and glossopharyngeal nerves are tested together because both innervate the pharynx. For testing, have the patient phonate by saying "ah," and note the bilateral symmetry of elevation of the soft palate. The gag reflex, which involves bilateral contraction of the palatal muscles, can be tested by touching the sides of the posterior pharynx or soft palate with a tongue blade. The cough reflex is used to test the glossopharyngeal and vagus nerves in intubated patients. The patient is told to shrug the shoulders when testing the accessory nerve. Midline protrusion of the tongue is significant in testing of the hypoglossal nerve. p. 1305

The nurse is caring for a patient with a diagnosis of frontal lobe dementia. What functional difficulties should the nurse expect in this patient? A. The lack of reflexes B. Endocrine problems C. Higher cognitive function abnormalities D. Respiratory, vasomotor, and cardiac dysfunction

C. Higher cognitive function abnormalities Rationale Because the frontal lobe is responsible for higher cognitive function, this patient may have difficulty with memory retention, voluntary eye movements, voluntary motor movement, and expressive speech. The lack of reflexes would occur if the patient had problems with the reflex arcs in the spinal cord. Endocrine problems would be evident if the hypothalamus or pituitary gland were affected. Respiratory, vasomotor, and cardiac dysfunction would occur if there was a problem in the medulla. p. 297

A patient reports decreased libido. Which part of the cerebrum has the potential for impaired functioning? A. Thalamus B. Basal ganglia C. Limbic system D. Hypothalamus

C. Limbic system Rationale The limbic system is located near the inner surfaces of the cerebral hemispheres and controls the sexual response and emotions. Impaired functioning of the limbic system may decrease libido. The thalamus relays the sensory and motor input to and from the cerebrum. The basal ganglia control and facilitate learned and automatic movements. The hypothalamus regulates endocrine and autonomic functions. p. 1297

Which activity is regulated by the Gamma-aminobutyric acid neurotransmitter? A. Sleep cycle B. Motor control C. Neuronal excitability D. Fight or flight response

C. Neuronal excitability Rationale Gamma-aminobutyric acid neurotransmitters help in regulating neuronal excitability. Serotonin neurotransmitters regulate the sleep cycle. Dopamine neurotransmitters help in regulating motor control. Norepinephrine neurotransmitters regulate the fight or flight response. p. 1295

The nurse reviews the magnetic resonance imaging (MRI) results of four patients. Which patient may be experiencing paralysis depending on the nurse's assessment? A. Patient A: Left cerebral cortex lesion B. Patient B: Cerebral cortex lesion C. Patient C: Lower motor neuro lesion D. Patient D: Right parietal cortex region

C. Patient C: Lower motor neuro lesion Rationale The cell bodies of lower motor neurons send axons to innervate the skeletal muscles of the legs, arms, and trunk, and, therefore control the body movements. A lower motor neuron lesion, as observed in Patient C, causes difficulty in body movement and is likely to result in paralysis. A left cerebral cortex lesion, observed in Patient A, results in dysphasia and speech difficulties. A cerebral cortex lesion, as observed in Patient B, causes apraxia. The patient with apraxia is unable to perform learned movements despite of having the physical ability to perform them. A lesion in the right parietal cortex, as seen in Patient D, may cause anosognosia, characterized by an inability to recognize a bodily defect or disease. p. 1296

A patient informs the nurse about having chest pain after being frightened when a fire broke out on the stove. Which division of the nervous system does the nurse recognize activates the "fight or flight" response? A. Central nervous system B. Peripheral nervous system C. Sympathetic nervous system D. Parasympathetic nervous system

C. Sympathetic nervous system Rationale The sympathetic nervous system is a part of the autonomic nervous system. It activates the mechanism of "fight or flight" in response to stress. The central nervous system integrates the received information as well as coordinates and influences the activities of all parts of the body. The peripheral nervous system sends information from the different body parts to the brain. The parasympathetic nervous system, also part of the autonomic nervous system, is responsible for stimulation of rest and digestion activities. p. 1299F

A patient presents with an inability to turn the eyes together in the same direction. Which nerves should be tested to detect paralysis of the eye muscle in this patient? Select all that apply. A. Optic nerve B. Olfactory nerve C. Trochlear nerve D. Abducens nerve E. Oculomotor nerve F. Hypoglossal nerve

C. Trochlear nerve D. Abducens nerve E. Oculomotor nerve Rationale The trochlear, oculomotor, and abducens nerves help in movements of the eyes. Therefore these three nerves should be tested together by asking the patient to hold the head steady and follow the movement of the nurse's finger with the eyes only. A normal response is parallel tracking of an object with both eyes. The optic nerve, hypoglossal nerve, and olfactory nerve do not play a role in eye movements. STUDY TIP: Record the information you find to be most difficult to remember on 3" × 5" cards and carry them with you in your pocket or purse. When you are waiting in traffic or for an appointment, just pull out the cards and review again. This "found" time may add points to your test scores that you have lost in the past. p. 1305

An extensor plantar response is associated with which nervous system abnormality? A. Brainstem lesions B. Lower motor neuron lesions C. Upper motor neuron lesions D. Lesions in the sensory cortex

C. Upper motor neuron lesions Rationale An upper motor neuron lesion results in an extensor plantar response in which the toes point up with plantar stimulation. Lesions in the sensory cortex result in paresthesia or an alteration in sensation. A brainstem lesion is characterized by ophthalmoplegia, which presents as paralysis of the eye muscles. Lower motor neuron lesions are characterized by diminished or absent motor responses. p. 1309

The nurse is assessing a patient with a recent stroke and observes that they do not appear to understand spoken words. What part of the cerebrum does the nurse recognize is damaged? A. Parietal lobe B. Broca's area C. Wernicke's area D. Superior temporal gyrus

C. Wernicke's area Rationale Wernicke's area of the cerebrum is involved in the integration of auditory language and understanding of spoken words. Broca's area regulates the verbal expression. The parietal lobe integrates somatic and sensory output. The superior temporal gyrus registers the auditory input. p. 1296

The nurse requests a patient to shrug the shoulders and turn the head side to side against resistance. Which cranial nerve is the nurse assessing? A. VI B. VII C. XI D. XII

C. XI Rationale Asking a patient to shrug shoulders and turn the head side to side against resistance is a method to test cranial nerve XI, the accessory nerve. Cranial nerves VI, VII, and XII have different methodologies of assessment. p. 1305

The nurse is performing a neurologic assessment for a patient. When assessing proprioception, what will the nurse have the patient do? Select all that apply. A. Ask the patients to repeat rapid, alternate movements. B. Ask the patient to recognize a familiar object by touch only. C. Ask the patient to flex and extend an arm against resistance. D. Ask the patient to stand with feet together and then close his or her eyes. E. Ask the patient the position of the big toe after moving it up and down with the patient's eyes closed.

D. Ask the patient to stand with feet together and then close his or her eyes. E. Ask the patient the position of the big toe after moving it up and down with the patient's eyes closed. Rationale Proprioception is the individual's ability to perceive the position of a body part with his or her eyes closed. The individual should be able to replicate the position of the body part accurately with the opposite extremity or describe the position verbally. A Romberg test is the test for proprioception. The patient is asked to stand with the feet together and then close his or her eyes. If the patient is able to maintain balance with the eyes open but sways or falls with the eyes closed (i.e., a positive Romberg test), vestibulocochlear dysfunction or disease in the posterior columns of the spinal cord may be indicated. Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care. p. 1307

A nurse is caring for a patient for whom the health care team suspects cerebral death. Which diagnostic procedure will the nurse prepare the patient for that will confirm this suspicion? A. Reflex test B. Myelogram C. Lumbar puncture D. Cerebral angiography

D. Cerebral angiography Rationale Cerebral angiography is a form of angiography that provides images of blood vessels in and around the brain. Lack of cerebral circulation is an important confirmatory test for cerebral death (brain death). A myelogram is an x-ray of the spinal cord and vertebral column performed after an injection of contrast medium into the subarachnoid space. Reflex tests help to assess the integrity of the nerve circuits and are performed to quickly confirm the integrity of the spinal cord or specific nerve root function. Lumbar puncture is done to aspirate cerebrospinal fluid. p. 1310

Graphesthesia is a test for which integrative sensory function? A. Reflexes B. Proprioception C. Vibration sense D. Cortical sensory

D. Cortical sensory Rationale Graphesthesia is a test for cortical sensory function. Reflexes are the contraction of a skeletal muscle that occurs when the tendon is stretched. Vibration sense is tested using a tuning fork that is placed on a bony prominence. The patient's proprioception is tested using the Romberg test. p. 1307

A patient states that he or she is having involuntary blinking. Which nerves should the nurse should evaluate? Select all that apply. A. Cranial nerve (CN) I B. Cranial nerve II C. Cranial nerve III D. Cranial nerve V E. Cranial nerve VII

D. Cranial nerve V E. Cranial nerve VII Rationale CN VII and CN V should be tested for blepharospasm. The corneal reflex test evaluates CN V and CN VII simultaneously. The sensory component of this reflex (corneal sensation) is innervated by the ophthalmic division of CN V; the motor component (eye blink) is innervated by the facial nerve (CN VII). CN I controls olfactory function. CN II controls optic function; CN III is responsible for oculomotor function. p. 1305

The nurse is caring for a patient who is experiencing increased intracranial pressure after a head injury. Which glial cell could be the reason for this condition? A. Microglia B. Astrocytes C. Schwann cells D. Ependymal cells

D. Ependymal cells Rationale Ependymal cells aid in the secretion of cerebrospinal fluid ( CSF). Increased secretion of CSF increases CSF pressure and intracranial pressure, resulting in herniation syndrome. Microglia is involved in phagocytosis. Astrocytes provide structural support to neurons. Schwann cells myelinate the nerve fibers in the periphery. p. 1295

The health care provider requests a skull x-ray for a patient. Which nursing intervention should the nurse perform to prepare the patient for the procedure? A. Encourage fluids. B. Withhold preceding meal. C. Instruct patient to empty the bladder. D. Explain that the procedure is noninvasive.

D. Explain that the procedure is noninvasive. Rationale It is important to explain to the patient that a skull x-ray is a noninvasive procedure. This will help to reduce patient anxiety. Nursing preparations such as encouraging fluids, withholding the preceding meal, and emptying bladder do not apply to a skull x-ray. These preparations are applied to procedures such as lumbar puncture, cerebral angiography, and positron emission tomography. Test-Taking Tip: Many times the correct answer is the longest alternative given, but do not count on it. NCLEX item writers (those who write the questions) are also aware of this and attempt to avoid offering you such "helpful hints." p. 1310

The nurse is assessing a patient who is experiencing altered taste. Which cranial nerve does the nurse assess during the patient's physical examination? A. Trochlear B. Vagus C. Hypoglossal D. Glossopharyngeal

D. Glossopharyngeal Rationale The glossopharyngeal nerve is connected to the medulla and has both sensory and motor functions. Damage to this nerve may result in altered taste. The trochlear nerve is the only cranial nerve that arises from the back of the brain stem. This nerve controls the superior oblique muscle of the eye. Paralysis of the trochlear nerve results in rotation of the eyeball upward and outward, leading to double vision. The vagus nerve is also connected to the medulla and has sensory, motor, and parasympathetic fibers. Damage to this nerve can result in gastroparesis. The hypoglossal nerve is connected to the medulla; its motor nerves are connected to the muscles of the tongue. Damage to this nerve can cause paralysis of the tongue. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. p. 1305

A nurse reviews a medical record of a patient who has had a stroke and notes that the medication route has been changed from parenteral to oral. Before administering the oral medications, which cranial nerves should the nurse assess? A. Facial and vagus B. Trigeminal and vagus C. Trigeminal and hypoglossal D. Glossopharyngeal and vagus

D. Glossopharyngeal and vagus Rationale Cranial nerves IX (glossopharyngeal) and X (vagus) control swallowing and the gag reflex. The nurse must assess the gag reflex before administering oral medications or feedings to prevent the risk of aspiration. Cranial nerve VII (facial) controls the motor function of the face and the taste sensation of the anterior two-thirds of the tongue. Cranial nerve V (trigeminal) controls sensation of the forehead, face, nasal cavity, teeth, and eyes, as well as the motor function of the muscles used for mastication. Cranial nerve XII (hypoglossal) controls the motor function of the intrinsic and extrinsic muscles of the tongue. p. 1305

A patient with a seizure disorder will undergo electroencephalography. Which nursing intervention should the nurse perform to prepare the patient for the procedure? A. Ensure that the patient has an empty bladder. B. Assess for contraindications to contrast media. C. Ensure that the patient has no metallic jewelry. D. Inform the patient that there is no danger of electric shock.

D. Inform the patient that there is no danger of electric shock. Rationale In electroencephalography, the electrical activity of the brain is recorded by scalp electrodes to evaluate seizure disorders. It is a noninvasive procedure and without any danger of electric shock. An empty bladder is not required for the test, because the electrodes are placed on the scalp. The patient may wear metal jewelry because their presence does not interfere with the test procedure. Metal jewelry may interfere in tests in which electromagnetic rays are passed through the body, for example, x-rays. The procedure does not involve injecting contrast media; therefore assessment of contraindications to contrast media is not applicable. p. 1311

During shift hand-off, the off-going registered nurse (RN) reports that the patient had a positive Romberg test on earlier examination. What will be the oncoming nurse's priority intervention? A. Elevate all four-side rails. B. Initiate seizure precautions. C. Place the patient on strict bedrest. D. Inform unlicensed assistive personnel (UAP) that the patient will need assistance with activity.

D. Inform unlicensed assistive personnel (UAP) that the patient will need assistance with activity. Rationale A positive Romberg test indicates that the patient is having difficulty with balance. The nurse will want to inform UAP that the patient is at risk for falls and will need assistance with activity. Elevating all four side rails is considered a restraint in many facilities and should be avoided. There is no indication that seizure precautions are needed. The positive Romberg test alone does not warrant that the patient be placed on strict bedrest, and doing so may lead to complications of immobility. STUDY TIP: Identify your problem areas that need attention. Do not waste time on restudying information you know. p. 1306

To test the function of the optic nerve (CN II), the nurse often uses a Snellen chart. If a Snellen chart is not available, what can the nurse use for this assessment? A. Penlight B. Amsler grid C. Ophthalmoscope D. Magazine or newspaper

D. Magazine or newspaper Rationale To test the function of the optic nerve (CN II), the nurse tests the visual acuity. If a Snellen chart is not available, asking the patient to read from a magazine or newspaper will give a gross assessment of acuity. The Amsler grid is used to detect macular degeneration. The ophthalmoscope is an instrument that is used for inspection of vessels and structures within the eye. STUDY TIP: Laughter is a great stress reliever. Watching a short program that makes you laugh, reading something funny, or sharing humor with friends helps decrease stress. p. 1305

The nurse is assessing a patient's facial nerve (CN VII) integrity. What should the nurse ask the patient to do? Select all that apply. A. Clench teeth B. Stick out tongue C. Say "ga, ga, ga" D. Raise eyebrows E. Purse lips together F. Close eyes tightly

D. Raise eyebrows E. Purse lips together F. Close eyes tightly Rationale To assess the motor function of the facial nerve (CN VII), assessments include asking the patient to raise eyebrows, close eyes tightly, purse the lips, perform an exaggerated smile, and frown. The nurse is looking for any asymmetry in facial movements. Clenching the teeth while palpating the masseter muscles is an assessment check for the trigeminal nerve (CN V). Extending the tongue assesses the hypoglossal nerve (CN XII). Asking the patient to say "ga, ga, ga" requires movement of the pharynx and tongue, thereby assessing cranial nerve IX, the glossopharyngeal. Test-Taking Tip: Become familiar with reading questions on a computer screen. Familiarity reduces anxiety and decreases errors. p. 1305

The nurse calls out the patient's name in an attempt to arouse them from sleep. What is the nurse assessing the integrity of? A. Reflex arc B. Limbic system C. Autonomic nervous system D. Reticular activating system (RAS)

D. Reticular activating system (RAS) Rationale The RAS requires communication among the brainstem, reticular formation, and cerebral cortex. The RAS is responsible for regulating arousal and sleep-wake transitions. The integrity of the reflex arc is assessed by performing reflex assessments, such as patellar and bicep reflexes. The limbic system concerns emotions, aggression, feeding behavior, and sexual response. The autonomic nervous system controls involuntary function of cardiac and smooth muscle and glands. Test-Taking Tip: Do not read too much into the question or worry that it is a "trick." If you have nursing experience, ask yourself how a classmate who is inexperienced would answer this question from only the information provided in the textbooks or given in the lectures. p. 1297

Which cranial nerve is responsible for the sense of hearing? A. VII (facial) B. I (olfactory) C. V (trigeminal) D. VIII (vestibulocochlear)

D. VIII (vestibulocochlear) Rationale Cranial nerve VIII (vestibulocochlear) is an auditory sensory nerve and is involved in equilibrium. Cranial nerve I (olfactory) is responsible for the sense of smell. Cranial nerve V (trigeminal) is responsible for chewing and many sensory nerves from the forehead to the lower jaw. Cranial nerve VII (facial) controls some of the motor functions of the face and taste. p. 1305

Which condition may be associated with a positive Romberg sign? Select all that apply. A. Absence of gag reflex B. Disorder of sensory cortex C. Diminished motor response D. Vestibulocochlear dysfunction E. Disease in posterior columns of the spinal cord

D. Vestibulocochlear dysfunction E. Disease in posterior columns of the spinal cord Rationale The Romberg test evaluates proprioception. The patient is asked to stand with the feet together and then close the eyes. If the patient is able to maintain balance with the eyes open but sways or falls with the eyes closed (i.e., positive Romberg test), vestibulocochlear dysfunction or disease in the posterior columns of the spinal cord may be indicated. Gag reflex is assessed by touching the sides of the posterior pharynx or soft palate with a tongue blade and assesses the function of the glossopharyngeal nerve. Disorder of sensory cortex is elicited by the two-point discrimination test. p. 1307