Chapter 36: Introduction to the Nervous System
The Glasgow Coma Scale is a common screening tool used for patients with a head injury. During the physical exam, the nurse documents that the patient is able to spontaneously open her eyes, obey verbal commands, and is oriented. The nurse records the highest score of: -5 -15 -10 -20
15 Explanation: A Glasgow Come Scale (GCS) score is based on three patient responses: eye opening, motor response, and verbal response. The patient receives a score for his best response in each area, and the three scores are added together. The total score will range from 3 to 15; the higher the number, the better. A score of 8 or lower usually indicates coma.
A patient arrives to have an MRI done in the outpatient department. What information provided by the patient warrants further assessment to prevent complications related to the MRI? -"I have not had anything to eat or drink since 3 hours ago." -"I am trying to quit smoking and have a patch on." -"My legs go numb sometimes when I sit too long." -"I have been trying to get an appointment for so long."
"I am trying to quit smoking and have a patch on." Explanation: Before the patient enters the room where the MRI is to be performed, all metal objects and credit cards (the magnetic field can erase them) must be removed. This includes medication patches that have a metal backing and metallic lead wires; these can cause burns if not removed (Bremner, 2005).
A nurse is discussing a lumbar puncture with a nursing student who observed the procedure. The student noticed that the cerebrospinal fluid was blood tinged and asks what that means. The correct reply is which of the following? -"It can mean a traumatic puncture or a subarachnoid bleed." "It can mean the spinal cord was damaged or a traumatic puncture." -"It can mean a bleed around the hypothalamus or damage from the needle." -"It can mean a subarachnoid bleed or damage to the spinal cord."
"It can mean a traumatic puncture or a subarachnoid bleed." Explanation: The needle is inserted below the level of the spinal cord, which prevents damage to the cord. The cerebral spinal fluid (CSF) should be clear and colorless. Pink or bloody CSF may indicate a subarachnoid bleed or local trauma from the puncture. The hypothalamus is located deep inside the brain and does not affect the color of the CSF.
The nurse is preparing a client for a neurological examination by the physician and explains tests the physician will be doing, including the Romberg test. The client asks the purpose of this particular test. The correct reply by the nurse is which of the following? -"It is a test for coordination." -"It is a test for muscle strength." -"It is a test for motor ability." -"It is a test for balance."
"It is a test for balance." Explanation: The Romberg test screens for balance. The client stands with feet together and arms at the side, first with eyes open and then with both eyes closed for 20 to 30 seconds. Slight swaying is normal, but a loss of balance is abnormal and is considered a positive Romberg test.
A client has been exhibiting neurological symptoms for several weeks and the neurologist is admitting the client to the hospital for extensive testing. Since diagnostics have not yet revealed the cause of the symptoms, which client statement would indicate the need for further client education? -"I need to be careful with my allergy to seafood!" - All of the comments indicate need for further client education. - "It's good to know the continual tingling in my fingers and toes is not connected with my nervous system!" - "There are several types of tests to see what's causing the tingling in my fingers and toes."
"It's good to know the continual tingling in my fingers and toes is not connected with my nervous system!" Explanation: The nervous system consists of the brain, spinal cord, and peripheral nerves.
A 26-year-old female client, who is breastfeeding a newborn, is due to undergo a computed tomography (CT) scan with dye contrast. What instruction should the nurse provide to the client based on this procedure? - "Do not breastfeed your baby for two weeks after the procedure as recommended by your provider." - "Do not eat or cook any shellfish prior to the procedure." - "Limit your intake of water and alcohol following the procedure." - "Stop breastfeeding for the time frame given by the provider within the nuclear medicine department."
"Stop breastfeeding for the time frame given by the provider within the nuclear medicine department." Explanation: Breastfeeding women are instructed by the nuclear medicine department to stop for a certain time period when undergoing nuclear medicine/CT scan treatment. Clients are assessed to see if an allergy to shellfish/iodine exists prior to the procedure. Clients are encouraged to drink plenty of fluids after the procedure to help the kidneys clear the dye out of the body.
A client for whom the nurse is caring has positron emission tomography (PET) scheduled. In preparation, what should the nurse explain to the client? -"The client will need to endure loud noises during the test." -"The test may result in dizziness or lightheadedness." -"An allergy to iodine precludes getting the radio-opaque dye." -"The test will temporarily limit blood flow through the brain."
"The test may result in dizziness or lightheadedness." Explanation: Key nursing interventions for PET scan include explaining the test and teaching the client about inhalation techniques and the sensations (e.g., dizziness, lightheadedness, and headache) that may occur. A PET scan does not impede blood flow through the brain. An allergy to iodine precludes the dye for an MRI, and loud noise is heard in an MRI.
The nurse is assessing the client's pupils following a sports injury. Which assessment findings indicate a neurologic concern? Select all that apply. -quick pupil reaction -pupil reacts to light -pinpoint pupils -unequal pupils -absence of pupillary response
-unequal pupils -pinpoint pupils -absence of pupillary response Explanation: Normal assessment findings include that the pupils are equal and reactive to light. Pupils that are unequal, pinpoint in nature, or fail to respond indicate neurologic impairment.
The Glasgow Coma Scale is a common screening tool used for patients with a head injury. During the physical exam, the nurse documents that the patient is able to spontaneously open her eyes, obey verbal commands, and is oriented. The nurse records the highest score of: -5 -20 -10 -15
15 Explanation: A Glasgow Come Scale (GCS) score is based on three patient responses: eye opening, motor response, and verbal response. The patient receives a score for his best response in each area, and the three scores are added together. The total score will range from 3 to 15; the higher the number, the better. A score of 8 or lower usually indicates coma.
A 78-year-old resident of a long-term care facility has left the majority of his supper tray untouched, and the nurse has asked him about the reason for this. The resident states, "For a long time now, food just doesn't taste as well as it used to." The nurse should be aware that the etiology of this problem is most likely to involve: -Cranial nerve dysfunction -Age-related changes to the neurological system -The development of a posterior spinal nerve lesion -An upper motor neuron lesion
Age-related changes to the neurological system Explanation: Decreased taste sensation is a normal, age-related change and is rarely the result of pathophysiological processes.
The nurse is caring for an 80-year-old client with a pre-existing history of dulled tactile sensation. The nurse should first consider what possible cause for this client's diminished tactile sensation? -An undiagnosed cerebrovascular accident in early adulthood -Damage to cranial nerve VIII -Adverse medication effects -Age-related neurologic changes
Age-related neurologic changes Explanation: Tactile sensation is dulled in the older adult client due to a decrease in the number of sensory receptors. While thorough assessment is necessary, it is possible that this change is unrelated to pathophysiologic processes.
Working hard to memorize the functions of the cranial nerves is a typical part of nursing school. Not only is it important to correlate the proper nerve number and name, but including the proper function makes this task quite a challenge! Which cranial nerves are enabling you to read this question? -All options are correct. -oculomotor -abducens -trochlear
All options are correct. Explanation: The oculomotor (III), abducens (VI) and trochlear (IV) nerves all work within the functional realm of the eyes. Don't forget the optic (II) nerve!
The nurse is performing a neurologic assessment of a client whose injuries have rendered the client unable to follow verbal commands. How should the nurse proceed with assessing the client's level of consciousness (LOC)? -Assess the client's eye opening and response to stimuli. -Facilitate diagnostic testing in an effort to obtain objective data. -Assess the client's vital signs and correlate these with the client's baselines. -Document that the client currently lacks a level of consciousness.
Assess the client's eye opening and response to stimuli. Explanation: If the client is not alert or able to follow commands, the examiner observes for eye opening; verbal response and motor response to stimuli, if any; and the type of stimuli needed to obtain a response. Vital signs and diagnostic testing are appropriate, but neither will allow the nurse to gauge the client's LOC. Inability to follow commands does not necessarily denote an absolute lack of consciousness.
The nurse is performing a neurologic assessment of a client whose injuries have rendered the client unable to follow verbal commands. How should the nurse proceed with assessing the client's level of consciousness (LOC)? -Assess the client's vital signs and correlate these with the client's baselines. -Document that the client currently lacks a level of consciousness. -Facilitate diagnostic testing in an effort to obtain objective data. -Assess the client's eye opening and response to stimuli.
Assess the client's eye opening and response to stimuli. Explanation: If the client is not alert or able to follow commands, the examiner observes for eye opening; verbal response and motor response to stimuli, if any; and the type of stimuli needed to obtain a response. Vital signs and diagnostic testing are appropriate, but neither will allow the nurse to gauge the client's LOC. Inability to follow commands does not necessarily denote an absolute lack of consciousness.
Which term refers to the inability to coordinate muscle movements, resulting in difficulty walking? -Agnosia -Ataxia -Spasticity -Rigidity
Ataxia Explanation: Ataxia is the inability to coordinate voluntary muscle action; tremors (rhythmic, involuntary movements) noted at rest or during movement suggest a problem in the anatomic areas responsible for balance and coordination. Agnosia is the loss of ability to recognize objects through a particular sensory system. Spasticity is the sustained increase in tension of a muscle when it is passively lengthened or stretched.
A client is scheduled for an EEG. The client asks about any diet-related prerequisites before the EEG. Which diet-related advice should the nurse provide to the client? -Decrease the amount of minerals in the diet. -Include an increased amount of minerals in the diet. -Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours before the test. -Avoid eating food at least 8 hours before the test.
Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours before the test. Explanation: The client is advised to refrain from taking sedative drugs or consuming drinks that contain caffeine at least 8 hours before the test because these may interfere with the EEG results. The client is not advised to increase or decrease the intake of minerals in the diet or to avoid eating food 8 hours before the test.
The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve? -CN IV -CN I -CN III -CN II
CN I Explanation: Cranial nerve (CN) I is the olfactory nerve, which allows the sense of smell. Testing of CN I is done by having the patient identify familiar odors with eyes closed, testing each nostril separately. An inability to smell an odor is a significant finding, indicating dysfunction of this nerve.
The nurse is assessing the pupils of a patient who has had a head injury. What does the nurse recognize as a parasympathetic effect? -One pupil is dilated and the opposite pupil is normal -Constricted pupils -Roth's spots -Dilated pupils
Constricted pupils Explanation: Constricted pupils are a parasympathetic effect; dilated pupils are a sympathetic effect.
The nurse is assessing the pupils of a patient who has had a head injury. What does the nurse recognize as a parasympathetic effect? -One pupil is dilated and the opposite pupil is normal -Dilated pupils -Roth's spots -Constricted pupils
Constricted pupils Explanation: Constricted pupils are a parasympathetic effect; dilated pupils are a sympathetic effect.
The nurse is assessing the pupils of a patient who has had a head injury. What does the nurse recognize as a parasympathetic effect? -Roth's spots -Dilated pupils -One pupil is dilated and the opposite pupil is normal -Constricted pupils
Constricted pupils Explanation: Constricted pupils are a parasympathetic effect; dilated pupils are a sympathetic effect.
There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected with decreased visual fields. -Cranial nerve I -Cranial nerve IV -Cranial nerve II -Cranial nerve III
Cranial nerve II Explanation: The three sensory cranial nerves are I, II and VIII. Cranial nerve II (optic) is affected with decreased visual fields and acuity.
Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities? -Decerebrate -Normal -Decorticate -Flaccid
Decorticate Explanation: Decorticate posturing is an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities and extension of the lower extremities. Decerebration is an abnormal body posture associated with a severe brain injury, characterized by extreme extension of the upper and lower extremities. Flaccidity occurs when the client has no motor function, is limp, and lacks motor tone.
The nurse is planning the care of a client with Parkinson disease. The nurse should be aware that treatment will focus on what pathophysiologic phenomenon? -Premature degradation of acetylcholine -Insufficient synthesis of epinephrine -Decreased availability of dopamine -Delayed reuptake of serotonin
Decreased availability of dopamine Explanation: Parkinson disease develops from decreased availability of dopamine, not acetylcholine, epinephrine, or serotonin.
Which is a sympathetic effect of the nervous system? -Increased peristalsis -Dilated pupils -Decreased blood pressure -Decreased respiratory rate
Dilated pupils Explanation: Dilated pupils are a sympathetic effect of the nervous system, whereas constricted pupils are a parasympathetic effect. Decreased blood pressure is a parasympathetic effect, whereas increased blood pressure is a sympathetic effect. Increased peristalsis is a parasympathetic effect, but decreased peristalsis is a sympathetic effect. Decreased respiratory rate is a parasympathetic effect, and increased respiratory rate is a sympathetic effect.
A trauma client in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death? -Electromyography (EMG) -Computed tomography (CT) -Electroencephalography (EEG) -Magnetic resonance imaging (MRI)
Electroencephalography (EEG) Explanation: The EEG can be used in determining brain death. MRI, CT, and EMG are not normally used in determining brain death.
A client has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important postprocedure nursing intervention should be performed to ensure the client's maximum comfort? -Keep the room brightly lit and play soothing music in the background -Help the client take a brisk walk around the testing area. -Administer antihistamines according to the physician's prescription. - Encourage the client to drink liberal amounts of fluids
Encourage the client to drink liberal amounts of fluids Explanation: The nurse should encourage the client to take liberal fluids and should inspect the injection site for swelling or hematoma. These measures help restore the volume of cerebrospinal fluid extracted. The client is administered antihistamines before a test only if he or she is allergic to contrast dye and contrast dye will be used. The room of the client who has undergone a lumbar puncture should be kept dark and quiet. The client should be encouraged to rest, because sensory stimulation tends to magnify discomfort.
Which safety action will the nurse implement for a client receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)? - Securely fasten the client's portable oxygen tank to the bottom of the MRI table after the client has been positioned on the table. - Check the client's oxygen saturation level using a pulse oximeter after the client has been placed on the MRI table. - Note that no special safety actions need to be taken. - Ensure that no client care equipment containing metal enters the room where the MRI table is located.
Ensure that no client care equipment containing metal enters the room where the MRI table is located. Explanation: For client safety the nurse must make sure that no client care equipment that contains metal or metal parts (e.g., portable oxygen tanks) enters the room where the MRI is located. The client must be assessed for the presence of medication patches with foil backing (e.g., nicotine patch) that may cause a burn. The magnetic field generated by the unit is so strong that any metal-containing items will be strongly attracted and can literally be pulled away with such great force that they can fly like projectiles toward the magnet.
The trochlear nerve controls which function? -Movement of the tongue -Eye muscle movement -Visual acuity -Hearing and equilibrium
Eye muscle movement Explanation: The trochlear nerve coordinates the muscles that move the eye. The acoustic nerve functions in hearing and equilibrium. The optic nerve functions in visual acuity and visual fields. The hypoglossal nerve functions in the movement of the tongue.
A patient had a lumbar puncture 3 days ago in the outpatient clinic and calls the nurse with complaints of a throbbing headache. What can the nurse educate the patient to do for relief of the discomfort? Select all that apply. -Get plenty of bed rest. -Walk around. -Take some over-the-counter analgesics. -Limit the amount of fluid to decrease cerebral edema. -Force fluids (unless contraindicated).
Force fluids (unless contraindicated). Get plenty of bed rest. Take some over-the-counter analgesics. Explanation: A postpuncture headache is usually managed by bed rest, analgesic agents, and hydration.
Which lobe of the brain is responsible for concentration and abstract thought? -Occipital -Frontal -Temporal -Parietal
Frontal Explanation: The major functions of the frontal lobe are concentration, abstract thought, information storage or memory, and motor function. The parietal lobe analyzes sensory information such as pressure, vibration, pain, and temperature. The occipital lobe is the primary visual cortex. The temporal lobe contains the auditory receptive areas located around the temples.
A patient is having a lumbar puncture and the physician has removed 20 mL of cerebrospinal fluid. What nursing intervention is a priority after the procedure? -Have the patient lie in a semi-Fowler's position with the head of the bed at 30º. -Early ambulation -Have the patient lie flat for 6 hours. -Have the patient lie flat for 1 hour and then sit for 1 hour before ambulating.
Have the patient lie flat for 6 hours. Explanation: Post-lumbar puncture headache may be avoided if a small-gauge needle is used and if the patient remains prone after the procedure. When more than 20 mL of CSF is removed, the patient is positioned supine for 6 hours (Bader & Littlejohns, 2010).
A neurological nurse is conducting a focused neurological assessment of a patient who has just been admitted to the rehabilitative facility. During this assessment, the nurse has asked the patient to swallow and has tested the patient's gag reflex with a tongue depressor. These assessments test the function of which of the patient's cranial nerves? -IV (trochlear) and V (trigeminal) -I (olfactory) and III (oculomotor) -IX (glossopharyngeal) and X (vagus) -VI (abducens) and VII (facial)
IX (glossopharyngeal) and X (vagus) Explanation: Assessing for the gag reflex tests the CN IX and CN X, as they travel together. CN X is also assessed by swallowing. The other listed cranial nerves are not tested by the gag reflex and swallowing ability.
A client is having a "fight or flight response" after receiving bad news about their prognosis. What affect will this have on the client's sympathetic nervous system? -Constriction of pupils -Constriction of bronchioles -Constriction of blood vessels in the heart muscle -Increase in the secretion of sweat
Increase in the secretion of sweat Explanation: Sympathetic nervous system stimulation results in dilated blood vessels in the heart and skeletal muscle, dilated bronchioles, increased secretion of sweat, and dilated pupils.
A patient has expressive speaking aphasia after having a stroke. Which portion of the brain does the nurse know has been affected? -Inferior posterior frontal areas -Posterior frontal area -Temporal lobe -Parietal-occipital area
Inferior posterior frontal areas Explanation: A deficiency in language function is called aphasia. Expressive speaking aphasia is associated with injury to the inferior posterior frontal areas, auditory receptive aphasia with the temporal lobe, expressive writing aphasia with the posterior frontal area, and visual receptive aphasia with the parietal and occipital areas.
A patient has expressive speaking aphasia after having a stroke. Which portion of the brain does the nurse know has been affected? -Posterior frontal area -Inferior posterior frontal areas -Temporal lobe -Parietal-occipital area
Inferior posterior frontal areas Explanation: A deficiency in language function is called aphasia. Expressive speaking aphasia is associated with injury to the inferior posterior frontal areas, auditory receptive aphasia with the temporal lobe, expressive writing aphasia with the posterior frontal area, and visual receptive aphasia with the parietal and occipital areas.
A client is scheduled for a myelogram, and the nurse explains to the client that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests? -MRI -Lumbar puncture -Cerebral angiography -EEG
Lumbar puncture Explanation: A myelogram is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. Client preparation for a myelogram would be similar to that for lumbar puncture. The other listed diagnostic tests do not involve lumbar puncture.
A patient is brought to the emergency room following a motor vehicle accident in which she sustained a head trauma. The patient is complaining of blindness in her left eye. The nurse would be correct in suspecting that this sensory deficit is related to damage in what cerebral lobe? -Parietal -Occipital -Frontal -Temporal
Occipital Explanation: The posterior lobe of the cerebral hemisphere is responsible for visual interpretation. The temporal lobe contains the auditory receptive areas. The parietal lobe contains the primary sensory cortex, and is essential to an individual's awareness of the body in space, as well as orientation in space and spatial relations. The frontal lobe functions in concentration, abstract thought, information storage or memory, and motor function.
A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis? -Risk for impaired skin integrity -Risk for falls -Decreased intracranial adaptive capacity -Risk for aspiration
Risk for aspiration Explanation: CN X, the vagus nerve, involves the gag reflex, laryngeal hoarseness, swallowing ability, and symmetrical rise of the uvula and soft palate. An impaired gag reflex indicates a danger for aspiration and subsequent pneumonia. An impaired vagus nerve will not affect balance, skin integrity, or intracranial adaptive capacity.
A patient has suffered cerebellar trauma after falling off of a ladder. The patient has been stabilized and is now receiving care on a neurological unit. When planning this patient's care, what nursing diagnosis is most likely to result from an injury to this part of the brain? -Risk for falls -Risk for ineffective thermoregulation -Risk for aspiration -Risk for ineffective breathing pattern
Risk for falls Explanation: The cerebellum is largely responsible for coordination of all movement. Injury thus results in a significant risk for falls. The cerebellum does not coordinate thermoregulation, swallowing, or respiration.
Following a traumatic brain injury, a client has been in a coma for several days. Which of the following statements is true of this client's current LOC? -The client is incapable of spontaneous respirations. -The client may occasionally make nonpurposeful movements. -The client occasionally makes incomprehensible sounds. -The client's current LOC will likely become a permanent state.
The client may occasionally make nonpurposeful movements. Explanation: Coma is a clinical state of unarousable unresponsiveness in which no purposeful responses to internal or external stimuli occur, although nonpurposeful responses to painful stimuli and brain stem reflexes may be present. Verbal sounds, however, are atypical. Ventilator support may or may not be necessary. Comas are not permanent states.
Following a traumatic brain injury, a client has been in a coma for several days. Which of the following statements is true of this client's current LOC? -The client's current LOC will likely become a permanent state. -The client may occasionally make nonpurposeful movements. -The client is incapable of spontaneous respirations. -The client occasionally makes incomprehensible sounds.
The client may occasionally make nonpurposeful movements. Explanation: Coma is a clinical state of unarousable unresponsiveness in which no purposeful responses to internal or external stimuli occur, although nonpurposeful responses to painful stimuli and brain stem reflexes may be present. Verbal sounds, however, are atypical. Ventilator support may or may not be necessary. Comas are not permanent states.
The spinal cord is composed of 31 pairs of spinal nerves. How many pairs of thoracic nerves are contained within the spinal column? -Five -Twelve -Eight -One
Twelve Explanation: There are twelve pairs of thoracic nerves, five lumbar and sacral nerves, eight cervical, and one coccygeal.
A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain? -V -IV -VI -III
V Explanation: The trigeminal nerve (cranial nerve V) innervates the forehead, cheeks, and jaw, so pain in the face elicited when brushing the teeth would most likely involve this nerve.
A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain? -VI -III -IV -V
V Explanation: The trigeminal nerve (cranial nerve V) innervates the forehead, cheeks, and jaw, so pain in the face elicited when brushing the teeth would most likely involve this nerve.
A client had a lumbar puncture performed at the outpatient clinic and the nurse has telephoned the client and family that evening. What does this intervention enable the nurse to determine? -Whether the client has had any complications of the test -Whether the client understood accurately why the test was done -What are the client's and family's expectations of the test -Whether the client's family had any questions about why the test was necessary
Whether the client has had any complications of the test Explanation: Contacting the client and family after diagnostic testing enables the nurse to determine whether they have any questions about the procedure or whether the client had any untoward results or complications. The other listed information should have been elicited from the client and family prior to the test.
A nurse is performing a neurologic assessment on a client. The nurse observes the client's tongue for symmetry, tremors, and strength, and assesses the client's speech. Which cranial nerve is the nurse assessing? -VI -XII -IV -IX
XII Explanation: Cranial nerve XII, the hypoglossal nerve, controls tongue movements involved in swallowing and speech. The tongue should be midline, symmetrical, and free from tremors and fasciculations. The nurse tests tongue strength by asking the client to push his tongue against his cheek as the nurse applies resistance. To test the client's speech, the nurse may ask him to repeat the sentence, "Round the rugged rock that ragged rascal ran." The trochlear nerve (IV) is responsible for extraocular movement (inferior medial). The glossopharyngeal nerve (IX) is responsible for swallowing movements and throat sensations. It's also responsible for taste in the posterior third of the tongue. The abducent nerves (VI) are responsible for lateral extraocular movements.
A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with: -body temperature control. -thinking and reasoning. -visual acuity. -balance and equilibrium.
body temperature control. Explanation: The body's thermostat is located in the hypothalamus; therefore, injury to that area can cause problems with body temperature control. Balance and equilibrium problems are related to cerebellar damage. Visual acuity problems would occur following occipital or optic nerve injury. Thinking and reasoning problems are the result of injury to the cerebrum.
A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with: -body temperature control. -visual acuity. -balance and equilibrium. -thinking and reasoning.
body temperature control. Explanation: The body's thermostat is located in the hypothalamus; therefore, injury to that area can cause problems with body temperature control. Balance and equilibrium problems are related to cerebellar damage. Visual acuity problems would occur following occipital or optic nerve injury. Thinking and reasoning problems are the result of injury to the cerebrum.
A nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? -normal -stupor -somnolence -comatose
comatose Explanation: The GSC is used to measure the LOC. The scale consists of three parts: eye opening response, best verbal response, and best motor response. A normal response is 15. A score of 7 or less is considered comatose. Therefore, a score of 6 indicates the client is in a state of coma and not in any other state such as stupor or somnolence. The evaluations are recorded on a graphic sheet where connecting lines show an increase or decrease in the LOC.
A typical spinal cord functions as a "highway" for sensory and descending motor neurons, providing conduction of impulses to and from the brain. The spinal cord is surrounded and protected by bony vertebrae, and ends between the: -first and second cervical vertebrae. -fourth and fifth thoracic vertebrae. -first and second thoracic vertebrae. -first and second lumbar vertebrae.
first and second lumbar vertebrae. Explanation: The spinal cord ends between the first and second lumbar vertebrae, where it divides into smaller sections called the cauda equine.
A client has been in a coma since being in a motor vehicle accident. Emergency surgery relieved intracranial pressure but, to date, the client has not regained consciousness. Which motor response is indicative of the most serious condition? -decorticate -decerebrate -flaccidity -comatose
flaccidity Explanation: The most ominous motor response is flaccidity, when the client makes no motor response.
To assess a client's cranial nerve function, a nurse should assess: -hand grip. -orientation to person, time, and place. -arm drifting. -gag reflex.
gag reflex. Explanation: The gag reflex is governed by the glossopharyngeal nerve, cranial nerve IX. The other choices would not be involved in a cranial nerve assessment. Hand grip and arm drifting are part of motor function assessment. Orientation is an assessment parameter related to a mental status examination.
The brain is a complex structure and is divided into three parts: the cerebrum, the cerebellum, and the brain stem. The brain stem consists of the midbrain, pons, and medulla oblongata. Which part of the brain contains regulatory centers for heartbeat, vasomotor activity, and breathing? -midbrain -cerebral cortex -pons -medulla oblongata
medulla oblongata Explanation: The medulla oblongata contains vital centers concerned with respiration, heartbeat, and vasomotor activity (the control of smooth muscle activity in blood vessel walls).
The brain is a complex structure and is divided into three parts: the cerebrum, the cerebellum, and the brain stem. The brain stem consists of the midbrain, pons, and medulla oblongata. Which part of the brain contains regulatory centers for heartbeat, vasomotor activity, and breathing? -midbrain -medulla oblongata -pons -cerebral cortex
medulla oblongata Explanation: The medulla oblongata contains vital centers concerned with respiration, heartbeat, and vasomotor activity (the control of smooth muscle activity in blood vessel walls).
The nurse is completing the physical assessment of a client suspected of a neurological disorder. The client reports having recently suffered a head trauma. In such a case, the nurse should: - not move or manipulate the client's head while assessing for bleeding or swelling. - explain the procedure of head assessment to the client before doing the assessment. - make the client sit in a chair and then assess his or her head for bleeding or swelling. - only move the client's head with the help of an assistant.
not move or manipulate the client's head while assessing for bleeding or swelling. Explanation: The nurse evaluates the client's body posture and any abnormal position of the head, neck, trunk, or extremities. The nurse carefully examines the head for bleeding, swelling, or wounds. The nurse does not move or manipulate the client's head during physical assessment, especially if there is a recent history of trauma.
The nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response? -observing the client's response to painful stimulus -observing the reaction of pupils to light -using the Romberg test -assessing the client's sensitivity to temperature, touch, and pain
observing the client's response to painful stimulus Explanation: The nurse evaluates motor response in a comatose or unconscious client by administering a painful stimulus. This action helps determine if the client makes an appropriate response by reaching toward or withdrawing from the stimulus. The Romberg test is used to assess equilibrium in a noncomatose client. Pupils are examined for their reaction to light to assess sensitivity in the third cranial (oculomotor) nerve. Sensitivity to temperature, touch, and pain is a test to assess the sensory function of the client and not motor response.
Cerebrospinal fluid (CSF) is manufactured in the ventricles and constantly circulates around the brain and spinal cord. The CSF functions as a cushion to protect structures and maintain relatively consistent intracranial pressure. Where does CSF circulate? -subpial space -subdural space -arachnoid space -subarachnoid space
subarachnoid space Explanation: The ventricles manufacture and absorb cerebrospinal fluid (CSF), which constantly circulates in the subarachnoid space of the brain and spinal cord.
A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in -intellectual function. -motor ability. -emotional status. -thought content.
thought content. Explanation: Hallucinations are disturbances of thought content. They are not disturbances in motor ability, intellectual function, or emotional status.
The nurse is assessing the client's pupils following a sports injury. Which assessment findings indicate a neurologic concern? Select all that apply. -absence of pupillary response -quick pupil reaction -pupil reacts to light -pinpoint pupils -unequal pupils
unequal pupils pinpoint pupils absence of pupillary response Explanation: Normal assessment findings include that the pupils are equal and reactive to light. Pupils that are unequal, pinpoint in nature, or fail to respond indicate neurologic impairment.
The nurse is assessing the client's pupils following a sports injury. Which assessment findings indicate a neurologic concern? Select all that apply. -quick pupil reaction -pinpoint pupils -absence of pupillary response -pupil reacts to light -unequal pupils
unequal pupils pinpoint pupils absence of pupillary response Explanation: Normal assessment findings include that the pupils are equal and reactive to light. Pupils that are unequal, pinpoint in nature, or fail to respond indicate neurologic impairment.
