Chapter 43: Nursing Assessment: Neurologic Function

To evaluate a client's cerebellar function, a nurse should ask:

"Do you have any problems with balance?"

A nurse is preparing a client for lumbar puncture. The client has heard about post-lumbar puncture headaches and asks how to avoid having one. The nurse tells the client that these headches can be avoided by doing which of the following after the procedure?

"Remain prone for 2 to 3 hours."

A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following?

"The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid."

Which of the following cerebrospinal fluid (CSF) pressure values would be indicative of increased intracranial pressure (ICP)?

22 mm Hg

Which of the following Glasgow Coma Scale scores indicates coma?

7

Which of the following neurotransmitters are deficient in myasthenia gravis?

Acetylcholine

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

Which of the following terms refers to the inability to coordinate muscle movements, resulting difficulty walking?

Ataxia

Lesions in the temporal lobe may result in which of the following types of agnosia?

Auditory

In a typical spinal cord, it functions as a "highway" for sensory and descending motor neurons - to provide conduction of impulses to and from the brain. The spinal cord is surrounded and protected by bony vertebrae. Where does the spinal cord end?

Between the first and second lumbar vertebrae

What part of the brain controls and coordinates muscle movement?

Cerebellum

A nurse is preparing a client for a lumbar puncture. The client has heard about post-lumbar puncture headaches and asks what causes them. The nurse tells the client that these headaches are caused by which of the following?

Cerebral spinal fluid leakage at the puncture site

The critical care nurse is giving report on a client they are caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the on-coming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate?

Comatose

In the divisions of the nervous systems, the basic structure is the neuron. The function of the neuron is determined by the direction of impulse transmission. Which part of the neuron is responsible for conducting impulses to the cell body?

Dendrites

Low levels of the neurotransmitter serotonin lead to which of the following disease processes?

Depression

Which of the following are sympathetic effects of the nervous system?

Dilated pupils

To implant an intracranial pressure monitor, what membranes will the surgeon need to penetrate? Choose all correct responses.

Dura mater • Arachnoid • Pia mater

Which of the following terms refer to a method of recording, in graphic form, the electrical activity of the muscle?

Electromyogram

Which lobe of the brain is responsible for concentration and abstract thought?

Frontal

Which of the following cerebral lobes is the largest and controls abstract thought?

Frontal

Cranial nerve IX is also known as which of the following?

Glossopharyngeal

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?

Lateral recumbent, with chin resting on flexed knees

The Family Nurse Practitioner is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?

Moving the head and chin toward the chest

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?

Occipital

Which of the following cranial nerves is responsible for muscles that move the eye and lid?

Oculomotor

The pre-nursing class is learning about the nervous system in their anatomy class. What part of the nervous system would the students learn is responsible for digesting food and eliminating body waste?

Parasympathetic

Which lobe of the brain is responsible for spatial relationships?

Parietal

A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture?

Position the client flat for at least 3 hours.

The Family Nurse Practitioner is assessing a 55-year-old who came to the clinic complaining of being "unsteady" on their feet. What would be a test for equilibrium?

Romberg test

Within our brains, 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?

Subarachnoid space

A client who has sustained a head injury to the parietal lobe cannot identify a familiar object by touch. The nurse knows that this deficit is which of the following?

Tactile agnosia

Which of the following cerebral lobes contains the auditory receptive areas?

Temporal

The brain is a complex structure and is divided into three parts: the cerebrum, the cerebellum, and the brain stem. The cerebrum is divided into two hemispheres and is further divided into four lobes per hemisphere. Which section of the brain controls and coordinates muscle movements?

The cerebellum

The nurse is performing a neurological assessment of a client who has sustained damage to the frontal cortex. Which of the following deficits will the nurse look for during assessment?

The inability to tell how a mouse and a cat are alike

A patient is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in which of the following?

Thought content

During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates:

cranial nerves IX and X.

After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an:

evaluation of the corneal reflex response.

Lower motor neuron lesions cause

flaccid muscle paralysis.

A female patient has undergone a lumbar puncture for a neurological assessment. The patient is put under the postprocedure care of a nurse. Which of the following important postprocedure nursing interventions should be performed to ensure maximum comfort to the patient?

Encourage a liberal fluid intake for the patient

What safety actions does the nurse need to take for a patient on oxygen therapy who is undergoing magnetic resonance imaging (MRI)?

Ensure that no patient care equipment containing metal enters the room where the MRI is located.

A male client is scheduled for an electroencephalogram (EEG). When the nurse caring for the client is preparing him for the test, the client states that during childhood he was mildly electrocuted but miraculously lived. Therefore, he is quite afraid of going through an EEG. In what ways can the nurse help dispel the client's fear regarding the test?

Inform the client that he will not experience any electrical shock.

Ada Zontor, a 60-year-old bookkeeper, is a client with the neurological group where you practice nursing. Mrs. Zontor has been exhibiting neurological symptoms for several weeks and the neurologist is admitting her to hospital for extensive testing. Since diagnostics have not yet revealed the cause of her difficulties, which of her following comments would indicate the 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!

A female client has undergone a lumbar puncture for a neurological assessment. The client is put under the post-procedure care of a nurse. Which of the following important post-procedure nursing interventions should be performed to ensure maximum comfort to the client? Choose all that apply.

• Encourage a liberal fluid intake for the client. • Position the client flat for at least three hours or as directed by the physician.

The nurse is completing the physical assessment of a patient suspected of a neurological disorder. The patient reports to the nurse that he has recently suffered a head trauma. In such a case, which of the following precautions should the nurse take for the patient? Select all that apply.

• The nurse should not move or manipulate the patient's head while assessing for bleeding or swelling.