MS III Test One
Cranial Nerve X: Vagus
-Function: sensory/motor impulses for larynx and pharynx; parasympathetic motor fibers supply smooth muscles of abdominal organs; sensory impulses from viscera -Testing procedure: tested in conjunction with cranial nerve IX
A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?
Administering a stool softener as ordered
Cerebellum
Balance and coordination
What diseases may impair sensory perception?
DM and PVD
If a client has a lower motor neuron lesion, the nurse would expect to observe which manifestation upon physical assessment?
Decreased muscle tone
Injury at C3-C4
Diaphragm control compromised. May not breathe on their own.
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
Cranial Nerve Pneumonic
On Occasion Our Trusty Truck Acts Funny, Very Good Vehicle Anyhow
Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?
Spasticity
A client with spinal trauma tells the nurse she cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?
Suction the airway.
Cranial Nerve V: Trigeminal
chewing, smiling Bells Palsy
Cranial Nerve IV: Trochlear
eye movement
Cranial Nerve III: Oculomotor
eyelid elevation, pupil constriction and accommodation Assess PERRLA
Cranial Nerve VII: Facial
facial expression; taste - anterior 2/3 of tongue; eyelid and lip closure
Cranial Nerve IX: Glossopharyngeal
gagging; swallowing - sensory; taste Disorder results in aspiration d/t dysphasia
Cranial Nerve VIII Vestibulocochlear
hearing and balance
Cranial Nerve VI: Abducens
innervates the lateral rectus muscle (abducts eye)
Cranial Nerve XII: Hypoglossal
movement of tongue
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, the nurse would anticipate a delayed reaction in:
response due to interrupted impulses from the central nervous system
Cranial Nerve I: Olfactory
sensory, smell
Cranial Nerve XI: Accessory
shoulder movement and head rotation
Cranial Nerve II: Optic
vision