exam 4

The nurse scores the client's level of consciousness (LOC) using the Glasgow Coma Scale. Which score should indicate to the nurse that the client needs emergency attention? A. a score of 9 B. A score of 11 C. A score of 12

A. a score of 9 Rationale: A score of 9 indicates that the client needs emergency attention. Scores greater than or equal to 11 are considered within normal range.

A client undergoes a scheduled electroencephalogram (EEG). Which post-procedure activity is most appropriate? A. Measure the heart and the pulse rate. B. Allow the client to wash hair and rest. C. Measure the level of consciousness (LOC) of the client.

B. Allow the client to wash hair and rest. Rationale: After an EEG, the nurse should ensure rest for the sleep-deprived client and allow the client to wash hair to remove the glue used to affix electrodes to the scalp. The client is advised not to take sedative drugs and caffeine-related drinks before the EEG; therefore, there is no reason to provide the client with them after the test. The nurse should not measure the LOC, the heart rate, or the pulse rate of the client unless advised by the health care provider.

The nurse is caring for a client with a significant allergy history to various medications and shellfish. Because the client needs to have a diagnostic study with contrast, which medication classification is anticipated? A. Bronchodilator B. Antihistamine C. Cardiotonic

B. Antihistamine Rationale: Clients with an allergy history are administered a pretest dose of an antihistamine. Antihistamines block histamine receptors and reduce the manifestations of an allergic reaction. The other options are not administered in the pretest period

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. Touch nose with one finger. B. Close eyes and stand erect. C. Close eyes and discriminate between dull and sharp.

B. Close eyes and stand erect. Rationale: 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 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 which cranial nerve? A. II B. VIII C. XI

B. VIII There are 12 pairs of cranial nerves. Cranial nerve VIII is the vestibulocochlear or auditory nerve responsible for hearing and balance. Cranial nerve II is the optic nerve. Cranial nerve VI is the abducens nerve responsible for eye movement. Cranial nerve XI is the accessory nerve and is involved with head and shoulder movement

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 XII

C. Cranial nerve XII Rationale: 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 and shoulder movement.

The nurse provides care for a client who is comatose and needs to collect motor response data. Which nursing action is appropriate? A. Using the Romberg test B. Observing the client's response to painful stimuli C. Monitoring the client's sensitivity to temperature, touch, and pain

C. Monitoring the client's sensitivity to temperature, touch, and pain Rationale: Assessment of motor function includes muscle movement, size, tone, strength, and coordination. The nurse evaluates motor response in the comatose or unconscious client by administering a painful stimulus to determine the client's response. An appropriate response is for the client to reach toward or withdraw from the stimulus. The Romberg test is used to assess equilibrium in a noncomatose client. Observing the reaction of the client's pupils to light is an oculomotor cranial nerve assessment. Monitoring sensitivity to temperature, touch, and pain assesses the sensory function of the client and not motor response.

Which neurons transmit impulses from the CNS? A. Sensory B. Dendrites C. Motor

C. Motor Neurons are either sensory or motor. Sensory neurons transmit impulses to the CNS; motor neurons transmit impulses from the CNS. A membranous sheath called the neurilemma covers the myelin of axons in peripheral nerves. Dendrites are nerve fibers.

The nurse is assessing the assigned client's level of consciousness during morning rounds. The nurse speaks the client's name, strokes the client's hand, and moves the client's shoulder. There is a delay, and then the client states, "What do you want?" Which level of consciousness should the nurse document? A. Conscious B. Semicomatose C. Somnolent

C. Somnolent Rationale: Somnolent or lethargy means that the client is drowsy or sleepy at inappropriate times. This is an improvement from the stuporous state, which includes arousing the client only with vigorous and repeated stimulation. A client that isconscious is alert and responds to stimulation immediately. A client is documented as semicomatose when the client only responds to superficial, relatively mild, painful stimuli.

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. What should the nurse tell the client?

C. That the covering is called myelin and that it can be discussed further at the next meeting. Rationale: Myelin is a fatty substance that covers some axons in the CNS and PNS. The nurse would be most correct in answering the question and then, if the client is tired, following up at the next meeting. It would also be appropriate to provide literature for the client to review at leisure. Discounting the client's need to know information about the disease process is belittling. Telling the client that more research needs to be done discounts the valuable information which is known.

A nurse is working in an outpatient studies unit administering neurological tests. The client is surprised that paste is used to secure an electroencephalogram and asks how it will be removed from the hair. With what substance does the nurse reply?

C. Shampoo Rationale: Shampoo removes the paste, which attached the electrodes to the head. Acetone is not used on the hair. There is no special soap needed. More than warm water is needed to lift and remove the paste.

The critical care nurse is giving 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. Somnolence C. Stupor

A. Comatose Rationale: The GSC is used to measure the LOC. The scale consists of three parts: eyeopening 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.

Which diagnostic procedure would the nurse anticipate performing first if the goal was to obtain a thin "slice" of a muscular body area? A. Computed tomography (CT) B. Magnetic resonance imaging (MRI) C. Positron emission tomography (PET)

A. Computed tomography (CT) ANS: A Rationale: A computer tomography scan uses x-rays and computer analysis to produce three-dimensional views of cross sections, or "slices," of the body. An MRI usesradiofrequency waves to produce images of tissue. PET scans use radioactive substances to examine metabolic activity and organ involvement. SPECT is an imaging tool that examines cerebral blood flow.

The nurse is assessing the client's pupils following a sports injury. Which assessment finding(s) indicates a neurologic concern? Select all that apply. A. Unequal pupils B. Pupil reaction quick C. Pinpoint pupils D. Absence of pupillary response E. Pupil reacts to light

A. Unequal pupils , C. Pinpoint pupils ,D. Absence of pupillary response Rationale: Normal assessment findings include the pupils being equal and reactive to light. Pupils that are unequal, pinpoint in nature, or fail to respond indicate a neurologic impairment.

The nurse assists the health care provider (HCP) in completing a lumbar puncture (LP). Which should the nurse note as a concern?

C. The cerebrospinal fluid (CSF) is cloudy in nature. Rationale: The CSF is normally clear and colorless; therefore, CSF that is cloudy would be noted by the nurse as a concern. The HCP is correct to maintain aseptic procedure. At 90 mm H20, the client's CSF fluid pressure falls within normal limits (between 80 and 100 mm H20). Sometimes the HCP will administer medication via intrathecal injection during an LP, which should not be a cause for concern.

A client presents to the emergency department status postseizure. The health care provider wants to measure CSF pressure. What test might be ordered on this client? A. Lumbar puncture B. Echoencephalography C. Nerve conduction studies

A. Lumbar puncture Rationale: Changes in CSF occur in many neurologic disorders. A lumbar puncture (spinal tap) is performed to obtain samples of CSF from the subarachnoid space for laboratory examination and to measure CSF pressure. Echoencephalography records the electrical impulses generated by the brain. Nerve conduction studies measure the speed with which the nerve impulse travels along the peripheral nerve. Electromyography studies the changes in the electrical potential of muscles and the nerves supplying the muscles.

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 shouldassess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly? A. Moving the head toward both sides B. Lightly tapping the lower portion of the neck to detect sensation C. Moving the head and chin toward the chest

C. Moving the head and chin toward the chest Rationale: 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 assessed