MED SURG EXAM 3 - CH 60
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?
1+
Which of the following terms is used to describe rapid, jerky, involuntary, purposeless movements of the extremities?
Chorea
Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed?
Clonus
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?
Comatose
The trochlear nerve controls which function?
Eye muscle movement
To assess a client's cranial nerve function, a nurse should assess:
Gag reflex
Cranial nerve IX is also known as which of the following?
Glossopharyngeal
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 flat for 6 hours.
The sympathetic and parasympathetic nervous systems have a direct effect on the circulatory system. Stimulation of the parasympathetic nervous system (PNS) causes which of the following?
Heartbeat to decrease
A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?
Helicopod
A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for:
Hypoxia
A comatose client is being cared for by a critical care nurse who documents that the client responds only to very painful stimuli by fragmentary, delayed reflex withdrawal. The nurse knows that reflexes in the body are centered where?
In the spinal cord
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
A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?
Lateral recumbent, with thighs flexed
Which term describes the fibrous connective tissues that cover the brain and spinal cord?
Meninges
Which neurons transmit impulses from the CNS?
Motor
A patient has difficulty interpreting his awareness of body position in space. Which lobe is most likely to be damaged?
Parietal
Which lobe of the brain is responsible for spatial relationships?
Parietal
Which of the following is a disorder due to a lesion in the basal ganglia?
Parkinson's
The nurse is caring for a client in the clinic who has come in to have an EMG done. How would the nurse prepare the client for this test?
Tell the client to expect some discomfort.
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?
VIII
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?
VIII
A client has sustained a head injury to the occipital area. He cannot identify a familiar object by looking at it. The nurse knows that this deficit is which of the following?
Visual agnosia
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?
XII
Age-related changes in the neurologic system must be carefully assessed. Which of the following changes does the nurse expect to find in some degree depending on the patient's age and medical condition? Select all that apply.
Decreased muscle mass, increased sensitivity to hot and cold, reduced papillary responses
A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates:
Dysfunction in the brain stem
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 am trying to quit smoking and have a patch on."
The nurse is assessing the pupils of a patient who has had a head injury. What does the nurse recognize as a parasympathetic effect?
Constricted pupils
A client suspected of having a distortion of cerebral arteries and veins is scheduled for a cerebral angiography. What would the nurse tell the client about the upcoming test?
Contrast will be given and a rapid sequence of radiographs will be taken.
During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to:
support the joint where the tendon is being tested.
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:
turning the client's head suddenly while holding the eyelids open
