med test 1
The nurse is caring for a stuporous client in the intensive care unit. Which assessment finding is documented to reflect an improvement in the client's level of consciousness?
Somnolent
The nurse is caring for a client in the emergency department with diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the client's face and torso. For which action, made by the nurse aide, would the nurse provide further instruction?
The nurse aide moved the client's head to clean behind the ears.
The brain stem holds the medulla oblongata. What is the function of the medulla oblongata?
Transmits motor impulses from the brain to the spinal cord
Which neurons transmit impulses from the CNS?
motor
The nurse is caring for a client who is undergoing single-photon emission computed tomography (SPECT). What is a potential side effect that this client may suffer?
Allergic reaction to the imaging material
A female client undergoes a scheduled electroencephalogram (EEG). Which of the following postprocedure activities should the nurse carry out for the client?
Allow the client to rest and shampoo the client's hair.
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?
Flaccidity
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 slowing transmission of the motor neurons, which deficits are anticipated?
A delayed reaction in response due to the interrupted impulses from the central nervous system
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?
Antihistamine
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?
Cerebral angiography
The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern?
Cerebrospinal fluid is cloudy in nature.
The critical care nurse is giving report on a client she is 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 oncoming nurse that the client has a LOC of 6. What does an LOC score of 6 in a client indicate?
Comatose
Which diagnostic procedure would the nurse anticipate first if the goal was to obtain a thin slice of a muscular body area?
Computed tomography (CT)
The nurse is caring for a post-lumbar puncture client experiencing an intense headache. The physician is notified and arriving to assess the client. If the physician chooses aggressive treatment, which nursing action is anticipated?
Drawing venous blood to perform a blood patch
A nurse is working in a neurologist's office. The physician orders a Romberg test. Which nursing action is correct?
Have the client close his eyes and stand erect.
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?
Lumbar puncture
The nurse is caring for a client in the neurologic intensive care unit. The nurse is noting from the assessment findings that the client is lacking a connection because 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?
Medulla oblongata
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
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?
Observing the client's response to painful stimulus
A nurse is completing a neurological assessment and determines that the client has significant visual deficits. A brain tumor is considered. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit?
Occipital
The nurse is assessing a client's ability to detect sensation in the upper extremity. Which nursing actions would be appropriate? Select all that apply.
Place a warm cotton ball on the arm. A gentle pinch using the fingers. Drag the alcohol pad over the skin. Touch the client with the pads of the finger.
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 nurse is caring for a client who is to have a lumbar puncture. What are the lowest vertebrae that contain the spinal cord?
Second lumbar vertebrae
The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse is correct to instruct on the action of which system?
Sympathetic nervous system
The nurse is caring for a client newly diagnosed with multiple sclerosis. The client indicates that there is so much to understand at one time. The client indicates understanding that there is a disruption in the covering of axons but does not remember what the covering is called. Which nursing action is correct?
Tell the client that the covering is called myelin and that you can discuss at the next meeting.
The client is waiting in a triage area to learn the medical status of his family following a motor vehicle accident. The client is pacing, taking deep breaths, and wringing the hands. Considering the effects in the body systems, what effects does the nurse anticipate in the liver?
The liver will convert glycogen to glucose for immediate use.
The nurse is working in an outpatient studies unit administering neurologic tests. The client is surprised that paste is used to secure an electroencephalogram and asks how it will be removed from the hair. The nurse is most correct to state which?
The paste is removed with standard shampoo.
The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply.
Unequal pupils Pinpoint pupils Absence of pupillary response
When completing a neurologic examination on a client, which question is most essential to evaluate the accuracy of the data?
When, if any, was your last narcotic use?
The nurse is scoring the client's level of consciousness using the Glasgow Coma Scale. Which score would indicate to the nurse that the client is in a semicomatose state?
a score of 9
The nurse is employed in a neurologist's office, 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?
cranial nerve VIII
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?
cranial nerve XII
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 conscious should the nurse document?
somnolent
A critical care nurse is documenting her assessment of a client she is caring for. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. What does this mean?
the client is not responding to stimuli