Chapter 60 Prepu: Assessment of Neurologic Function
A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction? a. "Don't eat anything for 12 hours before the test." b. "Don't shampoo your hair for 24 hours before the test." c. "Avoid stimulants and alcohol for 24 to 48 hours before the test." d. "Avoid thinking about personal matters for 12 hours before the test."
"Avoid stimulants and alcohol for 24 to 48 hours before the test." For 24 to 48 hours before an EEG, the client should avoid coffee, cola, tea, alcohol, and cigarettes because these may interfere with the accuracy of test results. (For the same reason, the client also should avoid antidepressants, sedatives, and anticonvulsants.) To avoid a reduced serum glucose level, which may alter test results, the client should eat normal meals before the test. The hair should be washed before an EEG because the electrodes must be applied to a clean scalp. The client's thoughts don't affect the test results.
To evaluate a client's cerebellar function, a nurse should ask: a. "Do you have any difficulty speaking?" b. "Have you noticed any changes in your muscle strength?" c. "Do you have any problems with balance?" d. "Do you have any trouble swallowing food or fluids?"
"Do you have any problems with balance?" To evaluate cerebellar function, the nurse should ask the client about problems with balance and coordination.
A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates: a. dysfunction in the spinal column. b. dysfunction in the brain stem. c. risk for increased intracranial pressure. d. dysfunction in the cerebrum.
Dysfunction in the brain stem. Decerebrate posturing indicates damage to the upper brain stem. Decorticate posturing indicates cerebral dysfunction. Increased intracranial pressure is a cause of decortication and decerebration.
Cranial nerve IX is also known as which of the following? a. Spinal accessory b. Glossopharyngeal c. Hypoglossal d. Vagus
Glossopharyngeal nerve: the 9th cranial nerve (CN IX). It is one of the four cranial nerves that has sensory, motor, and parasympathetic functions. The vagus nerve is cranial nerve X. Cranial nerve XII is the hypoglossal nerve. The spinal accessory is the cranial nerve XI.
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? a. "It can mean a traumatic puncture or a subarachnoid bleed." b. "It can mean a subarachnoid bleed or damage to the spinal cord." c. "It can mean the spinal cord was damaged or a traumatic puncture." d. "It can mean a bleed around the hypothalamus or damage from the needle."
"It can mean a traumatic puncture or a subarachnoid bleed." 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.
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? a. "The blood can repair damage to the spinal cord that occurred with the procedure." b. "The blood provides moisture at the site, which encourages healing." c. "The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid." d. "The blood will replace the cerebral spinal fluid that has leaked out."
"The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid." Loss of CSF causes the headache. Occasionally, if the headache persists, the epidural blood patch technique may be used. Blood is withdrawn from the antecubital vein and injected into the site of the previous puncture. The rationale is that the blood will act as a plug to seal the hole in the dura and prevent further loss of CSF. The blood is not put into the subarachnoid space. The needle is inserted below the level of the spinal cord, which prevents damage to the cord. It is not a lack of moisture that prevents healing; it is more related to the size of the needle used for the puncture.
The nurse is assessing the client's mental status. Which question will the nurse include in the assessment? a. "Are you having hallucinations now?" b. "Can you count backward from 100?" c. "Who is the president of the United States?" d. "Can you write your name on this piece of paper?"
"Who is the president of the United States? "Assessing orientation to time, place, and person assists in evaluating mental status. Does the client know what day it is, what year it is, and the name of the president of the United States? Is the client aware of where he or she is? Is the client aware of who the examiner is and why he or she is in the room? "Can you write your name on this piece of paper?" will assess language ability.
A potential complication of a hemorrhagic stroke is interference with the ability of the arachnoid villi to absorb CSF. Therefore, fluid in the ventricles increases beyond the amount that is usually absorbed daily, which is: a. 200 to 250 mL. b. 350 to 375 mL. c. 150 to 200 mL. d. 275 to 325 mL.
350 to 375 mL of this is usually absorbed daily. In the normal adult, approximately 500 mL of CSF is produced each day; all but 125 to 150 mL is absorbed by the villi (Hickey, 2009). When blood enters the system (from trauma or hemorrhagic stroke), the villi become obstructed, CSF is not absorbed, and hydrocephalus (increased size of ventricles) may result.
Which of the following neurotransmitters are deficient in myasthenia gravis? a. Dopamine b. Serotonin c. GABA d. Acetylcholine
Acetylcholine A decrease in the amount of acetylcholine causes myasthenia gravis. A decrease in serotonin leads to depression. Parkinson's disease is caused by a depletion of dopamine. Decreased levels of GABA may cause seizures.
Which term refers to the inability to coordinate muscle movements, resulting in difficulty walking?
Ataxia. 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.
Lesions in the temporal lobe may result in which type of agnosia? a. Relationship b. Visual c. Tactile d. Auditory
Auditory Lesions in the temporal lobe (lateral and superior portions) may result in auditory agnosia. Lesions in the occipital lobe may result in visual agnosia. Lesions in the parietal lobe may result in tactile agnosia. Lesions in the parietal lobe (posteroinferior regions) may result in relationship and body part agnosia.
What part of the brain controls and coordinates muscle movement? a. Cerebellum b. Cerebrum c. Midbrain d. Brain stem
Cerebellum The cerebellum, also known as the little brain, is responsible for smooth, coordinated voluntary movements. It is subdivided into three lobes: the anterior, posterior, and flocculonodular lobes. The cerebellum, which is located behind and below the cerebrum, controls and coordinates muscle movement.
The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm? a. Echoencephalography b. Electroencephalogram c. Myelogram d. Cerebral angiography
Cerebral angiography A cerebral angiography detects distortion of the cerebral arteries and veins . A myelogram detects abnormalities of the spinal canal. An electroencephalogram records electrical impulses of the brain. An echoencephalography is an ultrasound of the structures of the brain.
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? a. Traumatic puncture b. Not ambulating soon enough after the procedure c. Cerebral spinal fluid leakage at the puncture site d. Damage to the spinal cord
Cerebral spinal fluid leakage at the puncture site The headache is caused by cerebral spinal fluid (CSF) leakage at the puncture site. The supply of CSF in the cranium is depleted so that there is not enough to cushion and stabilize the brain. When the client assumes an upright position, tension and stretching of the venous sinuses and pain-sensitive structures occur.
A nurse is working in a neurologist's office. The physician orders a Romberg test. What should the nurse instruct the client to do? a. Close eyes and stand erect. b. Close eyes and discriminate between dull and sharp. c. Close eyes and jump on one foot. d. Touch nose with one finger.
Close eyes and stand erect. In the Romberg test, the client stands erect with the feet close together and eyes closed. If the client sways as if to fall, it is considered a positive Romberg test. All of the other options include components of neurologic tests, indicating neurologic deficits and balance.
The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve? a. Cranial nerve XII b. Cranial nerve XI c. Cranial nerve I d. Cranial nerve V
Cranial nerve XII: Hypoglossal Assessment of the movement of the tongue is related to cranial nerve XII, the hypoglossal nerve. Cranial nerve I is the olfactory nerve. Cranial nerve V is the trigeminal nerve responsible for sensation to the face and chewing. Cranial nerve XI is the spinal or accessory nerve responsible for head and shoulder movement.
Low levels of the neurotransmitter serotonin lead to which of the following disease processes? a. Seizures b. Myasthenia gravis c. Depression d. Parkinson's disease
Depression
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 post-procedure nursing intervention should be performed to ensure the client's maximum comfort? a. Administer antihistamines according to the physician's prescription b. Help the client take a brisk walk around the testing area c. Keep the room brightly lit and play soothing music in the background d. Encourage the client to drink liberal amounts of fluids
Encourage the client to drink liberal amounts of fluids 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.
Lower motor neuron lesions cause: a. increased muscle tone. b. no muscle atrophy. c. hyperactive and abnormal reflexes. d. flaccid muscles.
Flaccid muscles. Lower motor neuron lesions cause flaccidity, muscle atrophy, decreased muscle tone, and loss of voluntary control. Upper motor neuron lesions cause increased muscle tone. Upper motor neuron lesions cause no muscle atrophy. Upper motor neuron lesions cause hyperactive and abnormal reflexes.
Which anatomic part supplies cerebrospinal fluid to the subarachnoid space and down the spinal cord on the dorsal surface? a. Fourth ventricle b. Third ventricle c. Arachnoid villus d. Lateral ventricle
Fourth ventricle Cerebrospinal fluid (CSF), produced in the ventricles, is circulated around both the brain and the spinal cord by the ventricular system. The fourth ventricle supplies CSF to the subarachnoid space and down the spinal cord on the dorsal surface. The third and fourth ventricles connect via the aqueduct of Sylvius. The arachnoid villus is the area in the brain where CSF is absorbed.
A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure? a. Lateral recumbent, with thighs flexed b. Supine, with the knees raised toward the chest c. Lateral, with right leg flexed d. Prone, with the head turned to the right
Lateral recumbent, with thighs flexed To maximize the space between the vertebrae, the client is placed in a lateral recumbent position with the thighs flexed toward the chin as much as possible. The needle is inserted between L4 and L5. The positions in the other answer choices would not allow as much space between L4 and L5.
A 53-year-old man presents to the emergency department with a chief complaint of inability to form words and numbness and weakness in the right arm and leg. Where would you locate the site of injury? a. Right frontoparietal region b. Left basal ganglia c. Left frontoparietal region d. Left temporal region
Left frontoparietal region The patient is exhibiting signs of expressive aphasia with numbness/tingling and weakness in the right arm and leg. This indicates injury to the expressive speech center (Broca's area), which is located in the inferior portion of the frontal lobe. The motor strip is located in the posterior portion of the frontal lobe. The sensory strip is located in the anterior parietal lobe.
The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly? a. Moving the head toward both sides b. Gently pressing the bones on the neck c. Lightly tapping the lower portion of the neck to detect sensation d. Moving the head and chin toward the chest
Moving the head and chin toward the chest The neck is examined for stiffness or abnormal position. The presence of rigidity is assessed by moving the head and chin toward the chest. The nurse should not maneuver the neck if a head or neck injury is suspected or known. The neck should also not be maneuvered if trauma to any part of the body is evident. Moving the head toward the sides or pressing the bones on the neck will not help assess for neck rigidity correctly. While assessing for neck rigidity, sensation at the neck area is not to be assessed.
The nurse has completed evaluating the client's cranial nerves. The nurse documents impairment of the right cervical nerves (CN IX and CN X). Based on these findings, the nurse should instruct the client to a. refrain from eating or drinking for now. b. use the walker when walking. c. have their spouse bring in the client's glasses. d. wear any hearing aids while in the hospital.
Refrain from eating or drinking for now.
Which neurotransmitter demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways? a. Enkephalin b. Norepinephrine c. Acetylcholine d. Serotonin
Serotonin The brain stem, hypothalamus, and dorsal horn of the spinal cord are sources of serotonin. Enkephalin is excitatory and associated with pleasurable sensations. Norepinephrine is usually excitatory and affects mood and overall activity. Acetylcholine is usually excitatory, but the parasympathetic effects are sometimes inhibitory.
A patient has been diagnosed with damage to Broca's area of the left frontal lobe. To document the extent of damage, the nurse would assess the patient's: a. Hearing. b. Balance. c. Vision. d. Speech.
Speech The motor strip, which lies in the frontal lobe, anterior to the central sulcus, is responsible for muscle movement. It also contains Broca's area (left frontal lobe region in most people), critical for motor control of speech.
A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in a. emotional status. b. thought content. c. intellectual function. d. motor ability.
Thought content.
A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by: a. introducing ice water into the external auditory canal. b. shining a bright light into the pupil. c. touching the cornea with a wisp of cotton. d. turning the client's head suddenly while holding the eyelids open.
Turning the client's head suddenly while holding the eyelids open. To elicit the oculocephalic response, which detects cranial nerve compression, the nurse turns the client's head suddenly while holding the eyelids open. Normally, the eyes move from side to side when the head is turned; in an abnormal response, the eyes remain fixed.
A nurse is performing a neurologic assessment on the client and notes a positive Romberg test. This test for balance is related to which of the following cranial nerves? a. III b. VIII c. VII d. X
VIII CN VIII is the acoustic nerve. It has to do with hearing, air and bone conduction, and balance. CN X is the vagus nerve and has to do with the gag reflex, laryngeal hoarseness, swallowing ability, and the symmetrical rise of the uvula and soft palate. CN III is the oculomotor and has to do with pupillary response, conjugate movements, and nystagmus. CN VII is the facial nerve and has to do with the symmetry of facial movements and the ability to discriminate between the taste of sugar and salt.
The provider orders the Romberg test for a patient. The nurse tells the patient that the provider wants to evaluate his equilibrium by assessing which cranial nerve? a. VII b. III c. X d. VIII
VIII Cranial nerve VIII (acoustic) can be checked to assess equilibrium status.
A client is scheduled for standard EEG testing to evaluate a possible seizure disorder. Which nursing intervention should the nurse perform before the procedure? a. Maintain NPO status for 6 hours before the procedure b. Instruct the client that a standard EEG takes 2 hours c. Withhold anticonvulsant medications for 24 to 48 hours before the exam d. Sedate the client before the procedure, per orders
Withholding antiseizure medications for 24 to 48 hours prior to the exam Antiseizure agents, tranquilizers, stimulants, and depressants should be withheld 24 to 48 hours before an EEG because these medications can alter EEG wave patterns or mask the abnormal wave patterns of seizure disorders. To increase the chances of recording seizure activity, it is sometimes recommended that the patient be deprived of sleep the night before the EEG. Coffee, tea, chocolate, and cola drinks are omitted from the meal before the test because of their stimulating effect. However, the meal is not omitted, because an altered blood glucose level can cause changes in brain wave patterns. The patient is informed that the standard EEG takes 45 to 60 minutes; a sleep EEG requires 12 hours.
A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with: a. thinking and reasoning. b. balance and equilibrium. c. visual acuity. d. body temperature control.
body temperature control. 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.
Lower motor neuron lesions cause: a. no muscle atrophy. b. flaccid muscles. c. increased muscle tone. d. hyperactive and abnormal reflexes.
flaccid muscles. Lower motor neuron lesions cause flaccidity, muscle atrophy, decreased muscle tone, and loss of voluntary control. Upper motor neuron lesions cause increased muscle tone. Upper motor neuron lesions cause no muscle atrophy. Upper motor neuron lesions cause hyperactive and abnormal reflexes.
The nurse is caring for a patient who was involved in a motor vehicle accident and sustained a head injury. When assessing deep tendon reflexes (DTR), the nurse observes diminished or hypoactive reflexes. How will the nurse document this finding? a. 1+ b. 0 c. 2+ d. 3+
1+ Diminished or hypoactive DTRs are indicated by a score of 1+, no response by a score of 0, a normal response by a score of 2+, and an increased response by a score of 3+.
Which of the following terms is used to describe rapid, jerky, involuntary, purposeless movements of the extremities? a. Dyskinesia b. Spondylosis c. Chorea d. Bradykinesia
Chorea Chorea refers to involuntary spasmodic, purposeless, irregular, uncoordinated motions of the trunk and the extremities, as well as facial grimacing. Bradykinesia refers to slowed voluntary movements and speech. Dyskinesia refers to impaired ability to execute voluntary movements rather than involuntary movement. Spondylosis refers to degenerative arthritis of the cervical or lumbar vertebrae.
The critical care nurse is giving an end-of-shift report on a client. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? a. Comatose b. Normal c. Stupor d. Somnolence
Comatose 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.
The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart? a. CN I b. CN IV c. CN II d. CN III
Cranial nerve II: Optic nerve
To assess a client's cranial nerve function, a nurse should assess: a. gag reflex. b. arm drifting. c. orientation to person, time, and place. d. hand grip.
Gag reflex. 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.
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? a. Have the patient lie in a semi-Fowler's position with the head of the bed at 30º. b. Have the patient lie flat for 1 hour and then sit for 1 hour before ambulating. c. Early ambulation d. Have the patient lie flat for 6 hours.
Have the patient lie flat for 6 hours. 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
A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position? a. Supine with the head lower than the trunk b. Supine with feet raised c. Head of the bed elevated 45 degrees d. Prone
Head of the bed elevated 45 degrees After a myelogram, positioning depends on the dye injected. When a water-soluble dye such as metrizamide is injected, the head of the bed is elevated to a 45-degree angle to slow the upward dispersion of the dye. The prone and supine positions are contraindicated when a water-soluble contrast dye is used. The client should be positioned supine with the head lower than the trunk after an air-contrast study.
A nurse is noting from a client's neurologic assessment findings that the client's motor impulses are interrupted from the brain to the spinal cord. It also appears that the client lacks sensory impulses from the peripheral sensory neurons to the brain. Which area has the deficit? a. medulla oblongata b. pons c. subarachnoid space d. midbrain
Medulla oblongata Transmits motor impulses from the brain to the spinal cord. The medulla oblongata lies below the pons and transmits motor impulses from the brain to the spinal cord and sensory impulses from peripheral sensory neurons to the brain. The medulla contains vital centers concerned with respiration, heartbeat, and vasomotor activity (the control of smooth muscle activity in blood vessel walls).
The nurse is caring for a client in the emergency department with a diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the client's face and torso. Which action by the nurse aide would prompt the nurse to provide further instruction? a. Moving the client's head to clean behind the ears b. Cleaning the neck and upper chest area c. Using mild soapy water to clean the face d. Cleaning the eye area from the inner to the outer eye
Moved the client's head to clean behind the ears. Further instruction would be provided to the nurse aide when the nurse aide attempted to move the client's head to clean behind the ears. There should be no movement of the client's head when there is a history of head trauma. Cleaning the client's face with soapy water, cleaning the eye area, and cleaning the neck and upper chest are all appropriate actions completed by the nurse aide.
The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly? a. Gently pressing the bones on the neck b. Lightly tapping the lower portion of the neck to detect sensation c. Moving the head and chin toward the chest d. Moving the head toward both sides
Moving the head and chin toward the chest The neck is examined for stiffness or abnormal position. The presence of rigidity is assessed by moving the head and chin toward the chest. The nurse should not maneuver the neck if a head or neck injury is suspected or known. The neck should also not be maneuvered if trauma to any part of the body is evident. Moving the head toward the sides or pressing the bones on the neck will not help assess for neck rigidity correctly. While assessing for neck rigidity, sensation at the neck area is not to be assessed.
A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult that is slowing transmission of the motor neurons, what would the nurse anticipate a delayed reaction? a. Processing information transferred from the environment. b. Cognitive ability to understand relayed information. c. Identification of information due to slowed passages of information to the brain. d. Response due to interrupted impulses from the central nervous system
Response due to interrupted impulses from the central nervous system The central nervous system is composed of the brain and the spinal cord. Motor neurons transmit impulses from the central nervous system. Slowing transmission in this area would slow the response of transmission leading to a delay in reaction. Sensory neurons transmit impulses from the environment to the central nervous system, allowing identification of a stimulus. The cognitive centers of the brain interpret the information.
A client preparing to undergo a lumbar puncture states he doesn't think he will be able to get comfortable with his knees drawn up to his abdomen and his chin touching his chest. He asks if he can lie on his left side. Which statement is the best response by the nurse? a. "Although the required position may not be comfortable, it will make the procedure safer and easier to perform." b. "There's no other option but to assume the knee-chest position." c. "I'll report your concerns to the physician." d. "Lying on your left side will be fine during the procedure."
"Although the required position may not be comfortable, it will make the procedure safer and easier to perform." The nurse should explain that the knee-chest position is necessary to make the procedure safer and easier to perform. Lying on his left side won't make the procedure easy or safe to perform. The nurse shouldn't simply tell the client there is no other option because the client is entitled to understand the rationale for the required position. Reporting the client's concerns to the physician won't meet the client's needs in this situation.
A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects on the body systems, what does the nurse anticipate the liver will do? a. Maintain a basal rate of functioning. b. Convert glycogen to glucose for immediate use. c. Produce a toxic byproduct in relation to stress. d. Cease function and shunt blood to the heart and lungs.
Convert glycogen to glucose for immediate use. When the body is under stress, the sympathetic nervous system is activated readying the body for action. The effect of the body is to mobilize stored glycogen to glucose to provide additional energy for body action.
A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects on the body systems, what does the nurse anticipate the liver will do? a. Produce a toxic byproduct in relation to stress. b. Cease function and shunt blood to the heart and lungs. c. Maintain a basal rate of functioning. d. Convert glycogen to glucose for immediate use.
Convert glycogen to glucose for immediate use. When the body is under stress, the sympathetic nervous system is activated readying the body for action. The effect of the body is to mobilize stored glycogen to glucose to provide additional energy for body action.
The nurse is performing a neurologic assessment on a client diagnosed with a stroke and cannot elicit a gag reflex. This deficit is related to which of the following cranial nerves? a. III b. VIII c. X d. VII
Cranial Nerve X: Vagus Nerve The vagus nerve and has to do with the gag reflex, laryngeal hoarseness, swallowing ability, and the symmetrical rise of the uvula and soft palate. CN VII is the facial nerve and has to do with the symmetry of facial movements and the ability to discriminate between the tastes of sugar and salt. The inability to close one eyelid indicates impairment of this nerve. CN VIII is the acoustic nerve. It has to do with hearing, air and bone conduction, and balance. CN III is the oculomotor nerve and has to do with pupillary response, conjugate movements, and nystagmus.
There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected by decreased visual fields. a. Cranial nerve II b. Cranial nerve I c. Cranial nerve IV d. Cranial nerve III
Cranial nerve II The three sensory cranial nerves are I, II, and VIII. Cranial nerve II (optic) is affected with decreased visual fields and acuity.
A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain? a. V b. VI c. III d. IV
Cranial nerve V: Trigeminal nerve The trigeminal nerve innervates the forehead, cheeks, and jaw, so pain in the face elicited when brushing the teeth would most likely involve this nerve.
Which structural and motor change is related to aging and may be assessed in geriatric clients during an examination of neurological function? a. Decreased or absent deep tendon reflexes b. Increased pupillary responses c. Increased autonomic nervous system responses d. Enhanced reaction and movement times
Decreased or absent deep tendon reflexes Structural and motor changes related to aging that may be assessed in geriatric clients include decreased or absent deep tendon reflexes. Pupillary responses are reduced or may not appear at all in the presence of cataracts. There is an overall slowing of autonomic nervous system responses with aging. Strength and agility are diminished and reaction and movement times are decreased.
Which is a sympathetic effect of the nervous system? a. Decreased respiratory rate b. Increased peristalsis c. Dilated pupils d. Decreased blood pressure
Dilated pupils 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.
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: a. assessment of the client's gait. b. evaluation of bowel and bladder functions. c. examination of the fundus of the eye. d. evaluation of the corneal reflex response.
Evaluation of the corneal reflex response. During an acute crisis, the nurse should check the corneal reflex response to rapidly assess brain stem function. Other components of the brief initial neurologic assessment usually include level of consciousness, pupillary response, and motor response in the arms and legs. If appropriate and if time permits, the nurse also may assess sensory responses of the arms and legs. Emergency assessment doesn't include fundus examination unless the client has sustained direct eye trauma. The client shouldn't be moved unnecessarily until the extent of injuries is known, making gait evaluation impossible. Bowel and bladder functions aren't vital, so the nurse should delay their assessment.
A patient sustained a head injury during a fall and has changes in personality and affect. What part of the brain does the nurse recognize has been affected by this injury? a. Temporal lobe b. Frontal lobe c. Occipital lobe d. Parietal lobe
Frontal lobe The frontal lobe, the largest lobe, is located in the front of the brain. The major functions of this lobe are concentration, abstract thought, information storage or memory, and motor function. It contains Broca's area, which is located in the left hemisphere and is critical for motor control of speech. The frontal lobe is also responsible in large part for a person's affect, judgment, personality, and inhibitions
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? a. "My legs go numb sometimes when I sit too long." b. "I have been trying to get an appointment for so long." c. "I am trying to quit smoking and have a patch on." d. "I have not had anything to eat or drink since 3 hours ago."
I am trying to quit smoking and have a patch on. 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.
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? a. observing the client's response to painful stimulus b. observing the reaction of pupils to light c. assessing the client's sensitivity to temperature, touch, and pain d. using the Romberg test
Observing the client's response to painful stimulus 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.
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? a. Parietal b. Temporal c. Frontal d. Occipital
Occipital The occipital lobe is responsible for interpreting visual stimuli. The frontal lobe influences personality, judgment, abstract reasoning, social behavior, language expression, and movement. The temporal lobe controls hearing, language comprehension, and storage and memory recall (although memory recall is also stored throughout the brain). The parietal lobe interprets and integrates sensations, including pain, temperature, and touch; it also interprets size, shape, distance, and texture.
Which lobe of the brain is responsible for spatial relationships? a. Occipital b. Temporal c. Frontal d. Parietal
Parietal lobe Located above the occipital lobe and behind the frontal lobe, the parietal lobe plays a key role in sensory perception and integration, including spatial reasoning and the sense of body movement within the world. The parietal lobe is essential to a person's awareness of body position in space, size and shape discrimination, and right-left orientation. The frontal lobe controls information storage or memory and motor function. The temporal lobe contains the auditory receptive area. The occipital lobe is responsible for visual interpretation.
During a neurological assessment examination, the nurse assesses a patient for tactile agnosia. The nurse places a familiar door key in the patient's hand and asks him to identify the object with his eyes closed. The nurse documents his inability to identify the object and notes the affected area of the brain. Which of the following is the most likely affected area of the brain? a. Parietal lobe b. Occipital lobe c. Frontal lobe d. Temporal lobe
Parietal lobe The parietal lobe analyzes sensor information and relays the interpretation to the cortical area. Failure to identify a familiar object by touch is indicative of parietal lobe dysfunction.
During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to: a. support the joint where the tendon is being tested. b. hold the reflex hammer tightly. c. tap the tendon slowly and softly. d. use the pointed end of the reflex hammer when striking the Achilles tendon.
Support the joint where the tendon is being tested. The nurse should support the joint where the tendon is being tested to prevent the attached muscle from contracting. The nurse should use the flat, not pointed, end of the reflex hammer when striking the Achilles tendon. (The pointed end is used to strike over small areas, such as the thumb placed over the biceps tendon.) Tapping the tendon slowly and softly wouldn't provoke a deep tendon reflex response. The nurse should hold the reflex hammer loosely, not tightly, between the thumb and fingers so it can swing in an arc.
The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse should respond by describing the action of the: a. musculoskeletal system. b. parasympathetic nervous system. c. sympathetic nervous system. d. endocrine system.
Sympathetic nervous system. The division of the autonomic nervous system called the sympathetic nervous system regulates the expenditure of energy. The neurotransmitters of the sympathetic nervous system are called catecholamines. During an emergency situation or an intensely stressful event, the body adjusts to deliver blood flow and oxygen to the brain, muscles, and lungs that need to react in the situation. The musculoskeletal system benefits from the sympathetic nervous system as the fight-or-flight effects pump blood to the muscles. The parasympathetic nervous system works to conserve body energy not expend it during an emergency. The endocrine system regulates metabolic processes.
