Chapter 65 PrepU
A client presents to the emergency department status postseizure. The physician wants to know what the pressure is in the client's head. What test might be ordered on this client? A Lumbar puncture B Echoencephalography C Nerve conduction studies D EMG
A
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 Head of the bed elevated 45 degrees B Prone C Supine with feet raised D Supine with the head lower than the trunk
A
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 VIII B X C III D VII
A
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 "I am trying to quit smoking and have a patch on." B "I have been trying to get an appointment for so long." C "I have not had anything to eat or drink since 3 hours ago." D "My legs go numb sometimes when I sit too long."
A
Cranial nerve IX is also known as which of the following? A Glossopharyngeal B Vagus C Spinal accessory D Hypoglossal
A
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 have their spouse bring in the client's glasses. C wear any hearing aids while in the hospital. D use the walker when walking.
A
To evaluate a client's cerebellar function, a nurse should ask: a "Do you have any problems with balance?" b "Do you have any difficulty speaking?" c "Do you have any trouble swallowing food or fluids?" d "Have you noticed any changes in your muscle strength?"
A
What is the function of cerebrospinal fluid (CSF)? A It cushions the brain and spinal cord. B It acts as an insulator to maintain a constant spinal fluid temperature. C It acts as a barrier to bacteria. D It produces cerebral neurotransmitters.
A
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? A Distract the client's attention from the test. B Inform the client that he will not experience any electrical shock. C Inform the client that he will experience only mild electrical shock. D Encourage adequate water intake by the client.
B
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 VIII B X C III D VII
B
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 II c CN III d CN IV
B
There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected with decreased visual fields. A Cranial nerve I B Cranial nerve II C Cranial nerve III D Cranial nerve IV
B
A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure? A Prone, with the head turned to the right B Supine, with the knees raised toward the chest C Lateral recumbent, with thighs flexed D Lateral, with right leg flexed
C
A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain? A III B IV C V D VI
C
Which of the following cranial nerves is responsible for salivation, tearing, taste, and sensation in the ear? A Vestibulocochlear B Oculomotor C Facial D Trigeminal
C
What cranial nerve's function is the sense of smell?
CN I
What cranial nerve's function is vision?
CN II
What cranial nerve's function is raising eyelids, regulate pupil size, focus of lenses?
CN III
What cranial nerve's function is the eye movement?
CN IV
What cranial nerve's function is the taste and other sensations of the tongue?
CN IX
What cranial nerve's function is the sensation of the head and face, chewing movements and muscle sense?
CN V
What cranial nerve's function is the produce movements of the eyes?
CN VI
What cranial nerve's function is the facial expressions, secretion of saliva and taste?
CN VII
What cranial nerve's function is the balance or equilibrium sense and hearing?
CN VIII
What cranial nerve's function is the gag reflex and swallowing?
CN X
What cranial nerve's function is the turning movements of the head, shoulders?
CN XI
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? A Administer antihistamines according to the physician's prescription B Keep the room brightly lit and play soothing music in the background C Help the client take a brisk walk around the testing area D Encourage the client to drink liberal amounts of fluids
D
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 I B Cranial nerve V C Cranial nerve XI D Cranial nerve XII
D
To assess a client's cranial nerve function, a nurse should assess: A hand grip. B orientation to person, time, and place. C arm drifting. D gag reflex.
D
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 will seal the hole in the dura and prevent further loss of cerebral spinal fluid." b "The blood will replace the cerebral spinal fluid that has leaked out." c "The blood can repair damage to the spinal cord that occurred with the procedure." d "The blood provides moisture at the site, which encourages healing."
a
The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve? a CN I b CN II c CN III d CN IV
a
What part of the brain controls and coordinates muscle movement? a Cerebellum b Cerebrum c Midbrain d Brain stem
a
Which cranial nerve is responsible for muscles that move the eye and lids? a Oculomotor b Trigeminal c Vestibulocochlear d Facial
a
Which term refers to a method of recording, in graphic form, the electrical activity of a muscle? a. Electromyography b. Electroencephalography c. Electrocardiography d Electrogastrography
a An electromyogram is obtained by inserting needle electrodes into the skeletal muscles to measure changes in the electrical potential of the muscles. Electroencephalography is a method of recording, in graphic form, the electrical activity of the brain.Electrocardiography is performed to assess the electrical activity of the heart. Electrogastrography is an electrophysiologic study performed to assess gastric motility disturbances.
Which lobe of the brain is responsible for concentration and abstract thought? a Frontal b Parietal c Temporal d Occipital
a 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 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 Frontal b Occipital c Temporal d Parietal
b
The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern? a Physician maintains aseptic procedure. b Cerebrospinal fluid is cloudy in nature. c Client reports a piercing feeling. d Client reports pressure relief in the head.
b
The nurse is caring for a client who is to have a lumbar puncture. What are the lowest vertebrae that contain the spinal cord? a Coccyx b Second lumbar vertebrae c Eleventh thoracic vertebrae d Fifth lumbar vertebrae
b
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 sympathetic nervous system. c parasympathetic nervous system. d endocrine system.
b
Which cerebral lobes is the largest and controls abstract thought? a Temporal b Frontal c Parietal d Occipital
b
A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate? a Abnormal posture b Flaccidity c Weak muscular tone d Decorticate posturing
b The nurse would document flaccidity when the client makes no motor response to stimuli. Abnormal posturing and weak motor tone would be documented specifically as the nurse would assess. Decorticate posturing is when a client is stiff with bent arms and clenched fists with legs straight out.
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 Occipital lobe b Temporal lobe c Parietal lobe d Frontal lobe
c
The nurse is caring for a client newly diagnosed with multiple sclerosis who is overwhelmed by learning about the disease. The client indicates understanding that there is a disruption in the covering of axons but does not remember what the covering is called. The nurse should tell the client: a not to worry about the fine details. that because there is so much to learn, b there will be another meeting to discuss it again. c that the covering is called myelin and that it can be discussed further at the next meeting. d that the disease process requires more research.
c
The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of cranial nerve: a II b VI c VIII d XI
c
Which diagnostic test may be performed to evaluate blood flow within intracranial blood vessels? a computed tomography b Magnetic resonance imaging c Transcranial Doppler d Cerebral angiography
c
Which is a sympathetic effect of the nervous system? a Decreased blood pressure b Increased peristalsis c Dilated pupils d Decreased respiratory rate
c
A nurse conducts the Romberg test by asking the client to stand with the feet close together and the eyes closed. As a result of this posture, the client suddenly sways to one side and is about to fall when the nurse intervenes and prevents the client from being injured. In which way should the nurse interpret the client's result? a Positive Romberg test, indicating a problem with level of consciousness b Negative Romberg test, indicating a problem with body mass c Negative Romberg test, indicating a problem with vision d Positive Romberg test, indicating a problem with equilibrium
d
A patient who has suffered a stroke is unable to maintain respiration and is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe? a Frontal lobe b Occipital lobe c Parietal lobe d Brain stem
d
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: a cranial nerves I and II. b cranial nerves III and V. c cranial nerves VI and VIII. d cranial nerves IX and X.
d
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? a Central b Sympathetic c Peripheral d Parasympathetic
d
Which cerebral lobe contains the auditory receptive areas? a Frontal b Parietal c Occipital d Temporal
d
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? a Administer antihistamines to the client. b Provide adequate caffeine-rich drinks to the client. c Leave the client to rest and do not perform any assessments. d Position the client flat for at least 3 hours.
d A client who has undergone a lumbar puncture should be positioned flat for at least 3 hours and given adequate fluids. These measures help restore the cerebrospinal fluid volume extracted from the client and are priority activities
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 Myelogram b Electroencephalogram c Echoencephalography d Cerebral angiography
d The nurse would anticipate a cerebral angiography, which 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.