Neuro 308 Health Assessment
Which instruction would the nurse give to a patient while performing the Romberg test?
"Stand with feet together and eyes open then closed." A positive Romberg sign is the loss of balance that occurs when closing the eyes. The nurse asks the patient to stand up with the feet together and arms at the sides. Once in a stable position, the nurse instructs the patient to close the eyes and to hold the position and wait for about 20 seconds. Normally, a patient can maintain posture and balance even with the visual orienting information blocked, although slight swaying may occur. The nurse asks the patient to run the heel of the foot down the opposite shin to test cerebellar coordination and fine motor movements. Gait is evaluated by observing the patient walk heel to toe across the room. Rapid pronation and supination of the upper extremities tests abnormalities in diadochokinesia.
During testing of two-point discrimination in a patient's fingertips, what distance to distinguish between the two points would be normal?
2 to 8 mm Two-point discrimination refers to the patient's ability to distinguish the separation of two simultaneous pinpoints on the skin. The level of perception varies considerably with the region tested. On the fingertips, the two-point sensitivity is 2 to 8 mm. On the lips, it is 2 to 4 mm, and on the palms, it is 8 to 12 mm. The upper arms, thighs, and back are the least sensitive. The distance in those areas is 40 to 75 mm.
While assessing the deep tendon reflexes in a patient, the nurse finds that the responses are very brisk and hyperactive, with clonus. Which grade should the nurse enter in the patient's medical record?
4+ The nurse assesses the deep tendon reflexes to determine the intactness of the reflex arcs at the specific spinal levels. The nurse measures the reflex response on a 4-point scale. The nurse documents very brisk and hyperactive responses with clonus as grade 4+. This indicates that the patient has an upper motor neuron lesion. Grade 3+ responses are brisker than the average response. The nurse records average and normal responses as grade 2+. The nurse documents a diminished reflex that occurs only with reinforcement as a grade 1+ reflex.
The nurse is assessing a patient who is on long-term therapy for seizures. An assessment shows that the patient has a staggering gait and a positive Romberg sign. Which medication could cause these complications?
A barbiturate The health care provider may prescribe sedative medications such as barbiturates for the patient who is on long-term therapy for seizures. The cerebellum controls the balance and motor functions. Barbiturates such as phenobarbital (Luminal) directly act on the cerebellum and decrease its activity. Therefore, the patient who is on long-term barbiturate therapy may have a staggering gait and impaired balance, or positive Romberg sign. Anticonvulsant drugs such as phenytoin (Dilantin) are antiseizure medications that help to treat epilepsy or seizure disorder. Inability to sleep, weight loss, and decreased appetite are side effects of these drugs. Chlorpromazine is an antipsychotic medication; it may not be present in the prescription of a patient who has seizures. Dopaminergic drugs such as levodopa (Sinemet) increase the dopamine levels in the brain; they do not depress the cerebellum. Therefore, they do not cause staggering gait and impaired balance in the patient.
Which condition may cause decorticate posture in a patient?
A lesion in the cerebral hemispheres The patient with lesions in the hemispheres of the cerebral cortex may show decorticate posture. Decorticate posture involves flexion of the arms, extension of the lower extremities, and plantar flexion. The patient with cerebral damage may have difficulties associated with memory and thinking. Due to differential functions of the midbrain and pons, a lesion in the midbrain and upper pons may result in decerebrate posture, but not decorticate posture.
Which reflex helps the nurse assess the functioning of cranial nerve VIII (vestibulocochlear nerve) in an infant?
Acoustic blink reflex Cranial nerve VIII, or the vestibulocochlear nerve, aids in the transmission of impulses from the inner ear to the brain. The infant blinks in response to a loud hand clap 30 cm from the head. This is known as the acoustic blink reflex, and it helps to determine the functioning of cranial nerve VIII. Cranial nerve X controls the function of the pharyngeal muscles. The gag reflex helps to assess the functioning of cranial nerve X. Cranial nerve V innervates the muscles of the jaw. The sucking reflex enables the nurse to assess the functioning of cranial nerve V. The optical blink reflex helps to assess the functioning of cranial nerves I, III, IV, and VI, because these nerves control the intraocular and extraocular muscle functions.
The nurse observes a student nurse who is assessing pain perception in a patient. Which action of the student nurse needs correction?
Applying the tongue blade on the patient's body in a systematic order While assessing pain perception, the nurse breaks a tongue blade lengthwise and applies the sharp end to the patient's body randomly and unpredictably, but not in a regular order. This enables the nurse to assess pain perception in the patient accurately. The nurse uses the sharp edge of the tongue blade to test pain and the blunt end for assessing general responses. The nurse rightly discards the tongue blade to prevent the spread of infection to other patients. The nurse maintains a 2-second gap between each stimulus to avoid summation of the pain responses.
The nurse is assessing a patient who has a sensory cortex lesion. The nurse instructs the patient to close the eyes and places a key in the patient's hand. The nurse finds that the patient is unable to identify the object by touch. Which clinical sign does the patient's response indicate
Astereognosis A normal individual will be able to identify the object by touch, without seeing it. The patient with a sensory cortex lesion may have a decreased sensory perception. Astereognosis refer to the patient's inability to identify the object by touch. Rapid and rhythmic contractions of the same muscles indicate clonus. An abnormal, asymmetrical head or neck position is a sign of torticollis. Overactive or overresponsive reflexes indicate hyperreflexia in the patient.
Which type of tremor is most common in a patient with cerebral palsy?
Athetosis Athetosis is a type of tremor that occurs in the patient with cerebral palsy. Slow, twisting, writhing, continuous movements resembling those of a snake or worm characterize athetosis. It involves the distal part of the limb more than the proximal part of the limb. Sudden rapid, jerking movements of the limbs, trunks, or face indicate chorea. Chorea is common in the patient with Huntington's disease. Intention tremors are the involuntary contractions of the muscles which worsen during voluntary movements. This type of tremor is common in the patient with cerebellar disease or multiple sclerosis. Familial tremor is a type of intention tremor. Familial tremor is common in elderly patients.
How would an adult patient normally respond to the plantar reflex?
By flexing the toes The normal response to plantar reflex is flexion of the toes and inversion and flexion of the forefoot. Extension of the big toe and fanning of all toes is an abnormal response; however, it is normal in infants. This positive Babinski sign occurs with upper motor neuron disease of the corticospinal or pyramidal tract. If the stretched tendons of the flexed knee are struck just below the patella, extension of the lower leg will be the expected response. This is the quadriceps reflex. In the brachioradialis reflex, the relaxed forearm is stroked directly, about 2 to 3 cm above the radial styloid process. The normal response will be flexion and supination of the forearm.
While assessing a patient, the nurse notes that the patient cannot touch the tip of the nose with the forefinger. The patient also loses balance when the eyes are closed. Which disorder does the patient have?
Cerebellar dysfunction The cerebellum is concerned with the motor coordination of voluntary movements, equilibrium, and muscle tone. The postural balance of the body and complex and quick muscular coordination are its major functions. Hypoesthesia is a disorder in which the patient's touch sensation is decreased. Bell's palsy occurs because of a lower motor neuron lesion and causes paralysis of the entire half of the face. Meningeal irritation may lead to abnormal posture. Prolonged arching of the back, with head and heels bent backward, indicates meningeal irritation.
Which findings would the nurse observe in a patient with flaccid quadriplegia?
Complete loss of muscle tone and Paralysis of all four extremities Flaccid quadriplegia may occur due to a neurologic disease or trauma. Flaccid quadriplegia refers to complete loss of muscle tone and paralysis of all four extremities. It is caused by a completely nonfunctional brainstem. Prolonged adduction of the arm may occur in the patient with decorticate rigidity. A hyperextended back may occur with decerebrate rigidity. Prolonged arching of the back is a characteristic finding of the opisthotonos posture, which is caused by meningeal irritation.
The nurse is helping to stabilize a patient who is experiencing a generalized seizure. The patient has an increased heart rate and violent muscular contractions. When this current stage of the seizure passes, which symptoms does the nurse expect to see in the next stage?
Confusion Disorientation Excessive, hypersynchronous discharging of neurons in the brain may cause seizures. During the clonic phase of the seizure, the patient would have an increased heart rate and violent muscular contractions. During the postictal phase, which occurs directly after the clonic phase, the brain starts recovering from the seizure and the patient may experience confusion, disorientation, and often a deep sleep. Muscular rigidity occurs in the tonic phase of the generalized seizure, and during this phase the patient may have a high-pitched cry. Loss of consciousness occurs during the initial phase of a generalized seizure.
Which cranial nerve injury may cause anosmia in the patient?
Cranial nerve I (olfactory nerve) Cranial nerve I, or the olfactory nerve, innervates the olfactory bulb and mediates the sense of smell. Therefore, olfactory nerve injury may cause anosmia, or loss of the sense of smell in the patient. Cranial nerve II, which is also known as the optic nerve, innervates the eye and mediates the sense of vision. Therefore, optic nerve damage may cause loss of vision in the patient. Cranial nerves III and IV, which are also known as the oculomotor and trochlear nerves, respectively, innervate the muscles that aid in the movement of the eyeball. Therefore, damage to them may result in ptosis, or drooping eyelids.
Which cranial nerves more commonly undergo demyelination in a patient with multiple sclerosis?
Cranial nerve II Cranial nerve III Multiple sclerosis is an immune-mediated disease in which axons undergo inflammation, demyelination, degeneration, and finally sclerosis. Cranial nerve II (the optic nerve) and cranial nerve III (the oculomotor nerve) frequently undergo demyelination in patients with multiple sclerosis, resulting in nystagmus and diplopia. Damage to cranial nerve I (the olfactory nerve) may occur due to fracture of the cribriform plate, a lesion in the frontal lobe, or due to the presence of a tumor in the olfactory bulb. A tumor in the brainstem may cause damage to the abducens, or cranial nerve VI. Damage to cranial nerve VII, the facial nerve, is associated with Bell's palsy, but not multiple sclerosis.
While assessing neurologic function, the nurse touches a cotton wisp on the patient's forehead, cheeks, and chin. Which cranial nerve is the nurse testing?
Cranial nerve V The nurse is testing the sensory function of cranial nerve V (or the trigeminal nerve). This is the largest cranial nerve and it performs sensory functions related to the nose, eyes, tongue, and teeth. This nerve is further divided into ophthalmic, maxillary, and mandibular branches. The patient's light touch sensation is tested by touching a cotton wisp to these designated areas while the patient's eyes are closed. Cranial nerve IV (or the trochlear nerve) is a motor nerve that is connected to the midbrain and controls the eye muscles and turning of the eye. Cranial nerve VI (or the abducens nerve) helps in the lateral movement of the eyes, and cranial nerve VII (or the facial nerve) is responsible for various facial expressions. Because all of these are motor nerves, the light touch sensation test is not required for these cranial nerves.
While assessing a patient with lower motor neuron lesion, the nurse sees that the patient has an asymmetric smile and is unable to wrinkle the forehead. Damage to which cranial nerve could cause these findings?
Cranial nerve VII (facial nerve) A lower motor neuron lesion, asymmetric facial movements, and the inability to wrinkle the forehead indicate Bell's palsy in a patient. A patient with Bell's palsy may have paralysis of one half of the face. Cranial nerve VII, also known as the facial nerve, innervates the muscles of the face. Therefore, any damage to cranial nerve VII may lead to Bell's palsy in the patient. Cranial nerve II innervates the eye and mediates the sense of vision. Therefore, any damage to this nerve may lead to loss of vision, but not Bell's palsy. Cranial nerve III innervates the muscles of the eyeball; its damage may lead to ptosis or eyelid drooping. Cranial nerve VIII innervates the ear and mediates the sense of hearing. Therefore, its damage may lead to hearing impairment, but not Bell's palsy.
While performing an assessment, the nurse notes the absence of corneal, abdominal, and cremasteric reflexes on the right side of the patient's body. The patient shows spastic paralysis on the left side of the body. What is the probable reason for this condition?
Damage to the corticospinal tract The absence of the abdominal and cremasteric reflexes on right side and spastic motor paralysis on the left side indicate that the patient has hemiplegia due to an affliction of the left corticospinal tract. Cranial nerve IX mediates the process of swallowing; a defect in or damage to cranial nerve IX may cause difficulty in swallowing, not hemiplegia. This would not lead to the motor impairment on one side of the body. Demyelination of neurons may lead to multiple sclerosis, but not hemiplegia. Lower motor neuron damage causes flaccid paralysis, not spastic paralysis.
The nurse is caring for a patient who has resting tremors and abnormally slow movement. The nurse also observes flat expression, reduced eye blinking, and slouched posture in the patient. What reason does the nurse expect for these findings in the patient?
Degeneration of the dopamine-containing neurons Resting tremors, slow movement, or bradykinesia, flat expression, reduced eye blinking, and slouched posture indicate parkinsonism in the patient. It is a neurodegenerative disease of the central nervous system. It occurs due to the degeneration of the dopaminergic neurons in the substantia nigra of the brain. Damage to the cerebral cortex may cause cerebral palsy, but not parkinsonism. The patient with cerebral palsy may have seizures, but not resting tremors. Damage to the corticospinal tract and degeneration of the upper motor neurons may result in hemiplegia, which refers to the contralateral paralysis of the upper and lower limbs. The patient with hemiplegia will not necessarily have slouched posture. The patient with hemiplegia may have a posture characterized by an adducted shoulder, flexed elbow, pronated wrist, and extended leg.
Which test helps to screen the gross and fine motor coordination skills of an infant?
Denver II test The Denver II test helps to screen the gross and fine motor coordination skills in an infant. This test enables the nurse to assess whether the infant has achieved age-specific developmental motor skills. The nurse performs the Weber test to assess hearing ability of a patient. The Romberg test helps to assess the upright postural control in the patient. The nurse uses the heel-to-shin test to check the lower extremity coordination. These tests are performed in older children and adults.
Which conditions may cause peripheral neuropathy in a patient?
Diabetes mellitus, Nutritional deficiency Peripheral neuropathy involves the loss of sensory perception and numbness in the hands and feet. Diabetes mellitus and nutritional deficiencies may cause damage to the peripheral sensory nerves, leading to peripheral neuropathy. This microvascular damage may lead to peripheral neuropathy in the patient. Nutritional deficiency may lead to a decrease in the blood supply to the peripheral nerves, resulting in peripheral neuropathy. Cervical spondylosis may cause loss of all sensory modalities below the affected region. Shoulder dislocation may cause injury to individual nerves, not partial loss of sensation of the hands and feet. The pattern of sensory loss depends on the specific nerve injured. Meningioma may cause complete or partial loss of sensation on the contralateral side below the level of the lesion.
What should the patient's response be when the nurse tests the cremasteric reflex?
Elevation of the scrotum The cremasteric reflex is a male reflex. If the nurse lightly strokes the inner aspect of the patient's thigh with a reflex hammer or tongue blade, elevation of the scrotum should occur. Contraction of the quadriceps muscle occurs when the quadriceps reflex is tested. The anal wink or the anal reflex is the reflexive contraction of the external anal sphincter that is caused by stroking the skin around the anus. Stroking the lateral part of the sole of the foot with a sharp object produces plantar flexion of the big toe. This normal response is called the flexor plantar reflex.
Which areas of consciousness would a nurse rate while assessing a patient with the Glasgow Coma Scale?
Eye opening Verbal response Motor response The Glasgow Coma Scale is an accurate and reliable quantitative tool that defines the level of consciousness by giving it a numeric value. The scale is divided into three areas: eye opening, verbal response, and motor response. Each area is scored separately. The total score reflects the functional level of the brain. A fully alert healthy person has a score of 15, whereas a score of 7 or less reflects coma. Although assessments of the vital signs are important for a critically ill person, pulse rate and blood pressure are unreliable parameters of central nervous system deficit. Any changes are late consequences of rising intracranial pressure.
What are the characteristics of lower motor neuron lesions?
Fasciculation Muscular atrophy Marked muscular atrophy occurs mostly due to lower motor neuron lesions, whereas upper motor neuron lesions may cause little or no atrophy. Fasciculation refers to rapid and continuous twitching of the muscles. This occurs due to muscular atrophy and muscle weakness in a patient with lower motor neuron lesions. Spasticity refers to hypertonicity of the muscles. Lower motor neuron lesions may lead to hypotonia of the muscles, resulting in flaccidity. Lower motor neuron lesions may result in hyporeflexia or areflexia, but not hyperreflexia. Lower motor neurons do not control superficial reflexes such as the abdominal reflex. Loss of superficial abdominal reflexes may occur in the patient with upper motor neuron lesions.
Which abnormality of muscle tone would the nurse find in a patient with Guillain-Barré syndrome?
Flaccidity Guillain-Barré syndrome is a polyneuropathy which affects the lower motor neurons. In this condition, there is a decrease in the muscle tone, which leads to flaccidity. Rigidity indicates a constant state of resistance. The patient with Parkinson disease may have muscle rigidity. Upper motor neuron injury causes spasticity in which the muscle tone is increased. The patient with Parkinsonism may have cogwheel rigidity, in which increased tone is released intermittently with passive motion.
Which part of the brain is associated with personality and intellectual functioning?
Frontal lobe The frontal lobe is associated with personality, behavior, emotions, and intellectual functioning. The parietal lobe is associated with the processing of sensory information such as pressure, touch, and pain. The occipital lobe is the primary visual receptor center. The temporal lobe is associated with the functions of hearing, taste, and smell.
A patient who had a stroke is experiencing a severe throbbing headache, vomiting, and focal seizures. After reviewing the medical reports of the patient, the nurse confirms that the patient had a hemorrhagic stroke. Which condition could have caused the stroke?
Hemophilia Severe throbbing headache, vomiting, and focal seizures indicate a stroke in the patient. The patient with hemophilia will have a defect in the coagulation cascade. Therefore, any hemorrhage in the brain may lead to hemorrhagic stroke due to the defect in the clotting mechanism. Endocarditis and atrial fibrillation may lead to the formation of a moving clot or embolus in the blood vessels. Atherosclerosis may lead to the formation of a thrombus in the blood vessels. Therefore, endocarditis, atrial fibrillation, and atherosclerosis are associated with ischemic stroke, but not hemorrhagic stroke.
Which pathologic reflexes does the nurse observe in a patient with meningeal irritation?
Kernig's sign Brudzinski's sign The nurse may observe Kernig and Brudzinski signs in the patient with meningeal irritation, which may caused by meningeal infections or tumors. The patient with meningeal irritation may show resistance to straightening the leg while in supine position. This indicates a positive Kernig sign. A patient with a positive Brudzinski neck sign is characterized by resistance and pain in neck, caused by flexion of the hips and knees. Gordon sign, Babinski reflex, and Oppenheim sign are observed in the patient with pyramidal tract disease. Squeezing of the calf muscles may cause extension of the great toe and fanning of the other toes. This indicates a positive Gordon sign. Extension of the great toe and fanning of the toes upon stroking of the lateral aspect of the foot indicates positive a Babinski reflex. The nurse strokes the anterior tibial muscle while assessing the Oppenheim reflex in the patient. Extension of the great toe along with fanning of the toes indicates a positive Oppenheim sign.
While assessing an adult patient, the nurse observes stiff extension of the upper and the lower extremities, clenching of the teeth, and hyperextension of the back. What could be the cause of these findings in the patient?
Lesion in the upper pons Stiff extension of the upper and lower extremities, clenching of the teeth, and hyperextension of the back indicate decerebrate rigidity in the patient. A lesion in the upper pons of the midbrain may lead to the loss of certain motor reflexes, resulting in decerebrate rigidity. The patient with meningeal irritation may have an opisthotonos posture, but not decerebrate rigidity. Opisthotonos posture refers to the prolonged arching of the back with the head and heels bent backwards. Lesions in the cerebral cortex may cause decorticate rigidity, but not decerebrate posture. Decorticate rigidity is characterized by flexion of the arm, wrist, and fingers; adduction of the arm; and extension of the lower extremities, along with plantar flexion. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.
A patient presents with prolonged arching of the back with the head and heels bent backward. Which condition does the nurse suspect in the patient?
Meningeal irritation Prolonged arching of the back with the head and heels bent backward characterizes the opisthotonos posture. In this condition, meningeal irritation due to inflammation may lead to a decrease in the range of motion of the spine, leading to the prolonged arching of the back. The head of the patient may bend backward due to nuchal rigidity associated with the meningeal irritation. The patient with lesions in the brainstem may show extension of both upper and lower limbs, but not prolonged arching of the back. The patient with branchial plexus palsy may have asymmetry of upper limb movements, but not back hyperextension. The patient with lesions in the cerebral cortex may show flexion of the upper limbs and extension of the lower limbs, but not an opisthotonos posture.
Which signs would the nurse observe in a patient with Alzheimer disease?
Mood swings Disorientation Loss of initiative Alzheimer disease is a neurodegenerative disorder, and the patient may have memory loss due to the death of neurons in the cerebral cortex and subcortical regions. The patient may also have rapid mood swings due to the death of nerve cells. The patient with Alzheimer disease may have disorientation regarding time and place due the damage of the neurons in the cerebrum. The patient may become passive due to the loss of initiative, and thus may not participate in any social activities. The patient with multiple sclerosis may have diplopia due to the demyelination of the optic nerve, which is not a pathologic feature of Alzheimer disease. Bradykinesia is the characteristic sign of Parkinsonism, but not Alzheimer disease.
Which reflex finding in a 6-month-old infant would need immediate medical attention?
Moro reflex When an infant is startled suddenly by jarring the crib or making a loud noise, the infant abducts and extends the arms and legs. This reflex, called the Moro reflex, is present at birth, but disappears by 4 months of age. If the nurse observed the Moro reflex in an infant as old as 6 months, this could indicate severe central nervous system injury and would warrant immediate attention. The sucking reflex, Babinski reflex, and tonic neck reflex are normal findings in a 6-month-old infant and would not be a cause for concern. The sucking reflex disappears at the age of 10 to 12 months. The Babinski reflex is present at birth and disappears by 24 months of age. The tonic neck reflex disappears by 4 to 6 months of age.
Which statement precisely describes the efferent fibers?
Motor neurons carrying impulses to the muscles, organs, and glands A nerve is a bundle of fibers outside the central nervous system (CNS). The efferent fibers are the peripheral motor nerves; these nerves deliver output from the CNS to target organs like the muscles, organs, and glands. Sensory afferent fibers carry input to the CNS from the receptors. Upper motor neurons are complex descending motor fibers that can influence or modify the lower motor neurons. The pyramidal tract consists of motor nerve fibers that originate in the motor cortex and travel to the brainstem.
The nurse finds that a patient has crossed knees, fatigue, nystagmus, and diplopia. During the assessment, the nurse also observes that the patient is unable to maintain balance with the eyes closed. Which complication is present in the patient?
Multiple sclerosis Multiple sclerosis occurs due to inflammation of the axons, which results in demyelination of the neurons in the brain and the spinal cord. Multiple sclerosis affects the cerebellar system of the brain in a major way. Therefore, the patient will have impaired voluntary movements, which may lead to crossed knees and scissor gait. Because multiple sclerosis commonly involves demyelination of the optic nerves, the patient may have nystagmus and diplopia. The patient's inability to maintain balance after closing the eyes indicates a positive Romberg test. A positive Romberg test is a sign of multiple sclerosis. Slow, involuntary, convoluted, and writhing movements of the body resembling a snake indicate athetosis. The patient with athetosis might not have diplopia and nystagmus. Rapid, sudden jerking movements or a short series of jerks at regular intervals indicates myoclonus. It is caused by spinal cord injury or brain injury and is not associated with multiple sclerosis. The patient with meningitis may show an opisthotonos posture, but not crossed knees or scissor gait.
While assessing a patient with myasthenia gravis, the nurse sees that the patient has drooping upper eyelids. Damage to which cranial nerve could cause this finding?
Oculomotor The patient with myasthenia gravis may have ptosis, or drooping eyelids. The oculomotor nerve innervates the eye orbits and controls the movement of the eyes and eyelids. Therefore, any damage to cranial nerve III may result in drooping eyelids. Cranial nerve I is the olfactory nerve. It innervates the nose and helps in sense of smell; therefore, damage to this nerve may cause anosmia, but not drooping eyelids. The hypoglossal nerve innervates the tongue and controls its movement; damage to this nerve may cause difficulty in swallowing and speech, but not ptosis. The acoustic nerve innervates the ear and mediates the sense of hearing. Damage to this nerve may cause hearing impairment, but not ptosis.
After assessing a patient, the nurse suspects that a patient has a sensory cortex lesion. Which test did the nurse use for this assessment?
Point location test The point location test helps to assess the sense of touch, including the ability to localize the sense of touch. If a patient cannot pass this simple test, it could indicate a lesion in the sensory cortex. Cranial nerve VIII, or the vestibulocochlear nerve, transmits hearing impulses from the ear to the brain, and this function is tested by the Weber test. The finger-to-nose and finger-to-finger tests help to assess muscle coordination. They help to determine whether the patient has cerebellar dysfunction.
After assessing a 3-year-old child, the nurse suspects pyramidal tract disease. Which finding is consistent with this condition?
Positive Babinski reflex The Babinski reflex is present at birth and disappears by the age of 24 months. The presence of a Babinski reflex after 2 or 2.5 years of age indicates that the child has impaired function of the pyramidal tract. The child with pyramidal tract disease may have decreased functioning of the spinal cord. Extension of the limbs is a sign of intracranial hemorrhage. The presence of a Moro reflex after 5 months of age indicates severe central nervous system injury. However, central nervous system injury may not lead to pyramidal tract disease in the child. Asymmetry of the upper limb movements indicates brachial plexus palsy, not pyramidal tract disease.
Which tests should the nurse perform to assess cerebellar function in a patient?
Romberg test Finger-to-nose test The Romberg test is done to assess balance. The finger-to-nose test is done to assess upper limb coordination. This ability of an individual to perform these tests determines the cerebellar function of the patient. The extinction test is done to determine if an individual is able to perceive sensation upon touching both the sides of the body simultaneously. The stereognosis test is the ability of an individual to recognize objects by feeling their forms. The point location test is done to determine whether the patient is able to locate the area where he or she is touched. These tests are designed to assess the function of the sensory cortex.
Which tests should the nurse perform to assess cerebellar function in a patient?
Romberg test Finger-to-nose test The Romberg test is done to assess balance. The finger-to-nose test is done to assess upper limb coordination. This ability of an individual to perform these tests determines the cerebellar function of the patient. The extinction test is done to determine if an individual is able to perceive sensation upon touching both the sides of the body simultaneously. The stereognosis test is the ability of an individual to recognize objects by feeling their forms. The point location test is done to determine whether the patient is able to locate the area where he or she is touched. These tests are designed to assess the function of the sensory cortex.
What is the function of the fibers present in the posterior column?
Sensations of position and vibration The central nervous system has sensory pathways that take one of two routes—the anterolateral (spinothalamic) tract or the posterior (dorsal) columns. The fibers of the posterior columns conduct the sensations of position, vibration, and finely localized touch. The spinothalamic tract contains sensory fibers that transmit the sensations of temperature, crude or light touch, and pain.
The nurse asks the patient to close the eyes and then traces the number 5 on the patient's palm. The patient is unable to identify the number even after repeated attempts. This finding could indicate damage to what part of the patient's brain?
Sensory cortex Graphesthesia refers to an individual's ability to read a number or a letter traced onto the skin without seeing it. The patient with lesions of the sensory cortex has impaired sensory perception and thus will not be able to identify the number or letter traced on the palm. The cerebellum controls the voluntary movements of the body; the patient with cerebellar damage may have impaired voluntary functions, but not decreased sensory perception. Cranial nerve XII (hypoglossal) innervates the tongue and mediates the speech, swallowing, and chewing processes. Therefore, the patient with damage to cranial nerve XII would not have impaired graphesthesia. The patient with a lesion in the dorsal spinothalamic tract has a decreased sense of pain and temperature. Loss of graphesthesia sensation is not indicative of spinothalamic tract dysfunction.
What are the components of a reflex arc?
Sensory nerve Motor nerve Neuromuscular junction The myotatic reflex is made up of five components. The intact sensory nerve acts as an afferent neuron. The efferent pathway is controlled by an intact motor nerve fiber. The efferent pathway ends in the neuromuscular junction. Apart from these, a functional synapse in the cord and a competent muscle are also present in a reflex arc. A cranial nerve originates in the brain and is not a component of the reflex arc. A nucleus is a brain structure consisting of a relatively compact cluster of neurons. A reflex arc does not involve the brain; it involves the spinal cord and afferent and efferent neurons.
What are the components of a reflex arc?
Sensory nerve, Motor nerve, Neuromuscular junction The myotatic reflex is made up of five components. The intact sensory nerve acts as an afferent neuron. The efferent pathway is controlled by an intact motor nerve fiber. The efferent pathway ends in the neuromuscular junction. Apart from these, a functional synapse in the cord and a competent muscle are also present in a reflex arc. A cranial nerve originates in the brain and is not a component of the reflex arc. A nucleus is a brain structure consisting of a relatively compact cluster of neurons. A reflex arc does not involve the brain; it involves the spinal cord and afferent and efferent neurons.
While assessing the sense of smell, the nurse observes that the patient is unable to identify the odor of coffee. What conditions should the nurse further assess in the patient?
Sinusitis Allergic rhinitis Fracture of the cribriform plate Sinus infection, or sinusitis, refers to the presence of inflammation in the paranasal sinuses. Allergic rhinitis refers to the inflammation of the nasal airways in response to allergy. Sinusitis and allergic rhinitis increase mucus secretions of the nasal cavity, resulting in nasal congestion. These conditions may decrease the sense of smell. A fracture of the cribriform plate may lead to the leakage of cerebrospinal fluid into the nose, resulting in a decreased sense of smell. A brainstem tumor and increased intracranial pressure might not affect the function of the olfactory center of the brain. The patient with a brainstem tumor may not be able to move the eyeball properly. The patient who has increased intracranial pressure may have a throbbing headache and a dilated, nonreactive pupil.
The nurse flashes light into the eyes of a 5-year-old child and observes ocular misalignment and a deviated gaze. What condition does the nurse expect to find in the child?
Strabismus Strabismus is a condition in which the eyes are not aligned with each other. It may be caused by extraocular muscle incoordination, which ultimately results in gaze deviation. Nystagmus refers to the involuntary back-and-forth oscillation of the eyeball. Ocular misalignment will not lead to nystagmus in the child. Horner syndrome occurs due to the disruption of the sympathetic nerves that supply the eyes; it results in ptosis. Disruption of sympathetic nerves does not cause an alteration in the alignment of the eyes. Myasthenia gravis is a chronic condition that weakens various muscles of the body, including the eye muscles. This weakening leads to drooping of the eyelids, but not ocular misalignment.
What is the major function of the glossopharyngeal nerve?
Swallowing and gagging The glossopharyngeal nerve is cranial nerve IX. Its major motor function is to help in swallowing. The gag reflex, also known as a laryngeal spasm, is a reflex contraction of the back of the throat, evoked by touching the roof of the mouth, the back of the tongue, the area around the tonsils, and the back of the throat; the sensory limb of cranial nerve IX predominantly mediates this reflex. Lateral movement of the eye is controlled by the abducens nerve, or cranial nerve VI. The sensory part of the vagus nerve (cranial nerve X) contributes to the ability to taste. The hypoglossal nerve (cranial nerve XII) controls the muscular movement of the tongue.
Which lobe of the brain is associated with language comprehension?
Temporal lobe Wernicke's area, present in the temporal lobe, is associated with language comprehension. The frontal lobe controls the emotions and behaviors of a patient. The postcentral gyrus of the parietal lobe contains the primary center responsible for sensation. The occipital lobe contains the center that is responsible for vision.
How would a nurse test a patient's superficial reflex?
Test the reactions elicited by stroking the skin. Superficial reflexes are also called cutaneous reflexes. Here, the sensory receptors are in the skin rather than in the muscles. The motor response is a localized muscle contraction. If the skin of the patient is stroked with a reflex hammer, ipsilateral contraction of the skin occurs. Deep tendon reflexes are also known as the stretch reflex. Measurement of the stretch reflex reveals the intactness of the reflex arc at specific spinal levels. The nurse feels and sees rapid, rhythmic contractions of the calf muscles and the movement of the foot to test for clonus. To test the cremasteric reflex of the first two lumbar vertebrae, the nurse notes the elevation of the ipsilateral testicle in a male patient.
Which statement describes decerebrate rigidity?
The back is hyperextended, and the palms are pronated. In decerebrate rigidity, the upper extremities of the patient are stiffly extended and adducted. The palms are pronated, the teeth are clenched, and the back is hyperextended. It indicates a lesion in the brainstem at the midbrain or upper pons. In decorticate rigidity, the arms are flexed and adducted (i.e., tight against the thorax), and the legs are extended with plantar flexion. This indicates a hemispheric lesion of the cerebral cortex. In flaccid quadriplegia, complete loss of muscle tone and paralysis of all four extremities occur. It indicates a completely nonfunctional brainstem. Prolonged arching of the back, with the head and heels bent backward, is a symptom of opisthotonos. This indicates meningeal irritation.
While examining an 8-month-old infant, the nurse observes a palmar grasp reflex. What does the nurse infer from this finding?
The infant may have a frontal lobe lesion. The nurse assesses the palmar grasp reflex in the infant by offering a finger to the infant from the ulnar side. If the infant grasps the finger tightly, it indicates the presence of palmar grasp reflex. This reflex appears at birth and disappears at the age of 3 to 4 months. Persistence of the palmar grasp beyond the age of 4 months may indicate the presence of a lesion in the frontal lobe. This reflex is not a common finding in the 8-month-old infant. Nerve injury may lead to the loss of the palmar grasp reflex. Damage to the occipital lobe will result in visual problems in the infant.
The nurse pinches the nose of an infant to assess the functioning of cranial nerve XII (hypoglossal). Which response of the infant indicates a normally functioning cranial nerve XII?
The infant opens the mouth and raises the tongue. Cranial nerve XII innervates the tongue. The infant with normal functioning of cranial nerve XII opens the mouth and raises the tongue in the midline when the nurse pinches the nose. Cranial nerve VII aids in the movement of the facial muscles. Therefore, the nurse checks for the forehead wrinkle while assessing the functioning of the cranial nerve VII. Cranial nerve IV aids in the movement of the eye muscles. Therefore, the nurse expects blinking of the eye while assessing the function of the cranial nerve IV. The infant with normal cranial nerve VII function will have symmetrical facial movements while crying and smiling. However, the nurse will not check this while assessing for the cranial nerve XII.
What percentage of the population has a dominant left hemisphere, including those who are left-handed?
The left hemisphere is dominant in about 95% of people, including those who are left-handed.
The nurse is caring for a patient with a seizure disorder. The nurse observes that the patient is in the tonic phase of a generalized seizure. Which findings enabled the nurse to reach such a conclusion?
The patient bites the tongue. The patient opens the mouth and the eyes. Excessive and abnormal neuronal activity in the brain may cause seizures in the patient. The different phases of a generalized seizure include loss of consciousness followed by the tonic phase, clonic phase, and postictal phase. The patient will have muscle rigidity during the tonic phase, and may bite the tongue, open the mouth, and cry in a high-pitched voice during the tonic phase. Increased heart rate, facial grimace, and violent muscular contractions characterize the clonic phase. The postictal phase is the last phase of a generalized seizure and is characterized by deep sleep, disorientation, and confusion.
A patient reports a loss of pain and temperature sensation in the right lumbar region. The patient has also lost the sensations of vibration and position discrimination on the left side of the lumbar region. What does the nurse understand from these findings?
The patient has Brown-Séquard syndrome. Brown-Séquard syndrome is a condition that occurs due to a lesion in the spinal cord. It may be caused by meningioma, neurofibroma, or cervical spondylosis. The symptoms of the syndrome are the loss of the sense of the pain and temperature on the contralateral side of the lesion and the loss of vibration and position discrimination on the ipsilateral side, below the level of the lesion. Chorea is characterized by abnormal rapid, jerky, purposeless movements of the limbs, trunks, or face.The patient with chorea may not have decreased sensory perception. Peripheral neuropathy is characterized by loss of sensation in the upper and lower limbs. Flaccid quadriplegia refers to the paralysis of all the four extremities and the complete loss of the muscle tone, but not decreased sensory perception.
While assessing a patient, the nurse finds that the patient has difficulty swallowing and some ingested fluids are regurgitated through the nose. What does the nurse infer about the patient's neurologic condition from these findings?
The patient has bilateral lesions on cranial nerve X. Cranial nerve X is also known as the vagus nerve, and it innervates the heart and the digestive tract. The patient with bilateral lesions on the vagus nerve may have difficulty swallowing, and the fluids may be regurgitated through the nose. Cranial nerve XII, which is also known as the hypolossal nerve, innervates the tongue and controls the movement of the tongue. Therefore, the patient with a cranial nerve XII lesion may have a slow rate of movement of the tongue. Cranial nerve V, which is also referred to as the trigeminal nerve, innervates the muscles of the jaw. Therefore, the patient with a unilateral cranial nerve V lesion may have weakness of the jaw muscles. Cranial nerve III, which is also referred to as the oculomotor nerve, innervates the muscles of the eyeball. Therefore, the patient with cranial nerve III paralysis may have dilated pupils and ptosis, or drooping eyelids.
Which sign or symptom would the nurse expect to find in a patient with aphasia?
The patient has lost the ability to understand language. The inability to understand or use language is often associated with aphasia. It is caused by the dysfunction of Wernicke's area in the temporal lobe or Broca's area in the frontal lobe of the brain. Anosmia is the inability to perceive odor or a lack of functioning olfaction. Astasis is a lack of motor coordination marked by an inability to stand, walk, or even sit without assistance because of the disruption of muscle coordination. Ageusia is the loss of the taste functions of the tongue. A person with ageusia will be unable to detect sweetness, sourness, bitterness, or saltiness.
A patient is given a score of 3 on the Glasgow Coma Scale. What does this score indicate?
The patient is in a coma. A score of 7 or less on the Glasgow Coma Scale (GCS) indicates that the patient is in a comatose condition; a score of 3 is given to a patient who is totally unresponsive. A fully alert patient should have a GCS score of 15. The GCS is used to determine the functional state of the brain, not of any particular site in the brain. A patient who is able to obey commands would receive a GCS score of more than 6.
While reviewing the neuroimaging reports of a patient who was in an accident, the nurse sees that the patient's cerebellum is damaged. What is the most likely result of this injury?
The patient may have impaired voluntary movements. The cerebellum is a part of the brain concerned with motor coordination of voluntary movements, equilibrium, and muscle tone. Any damage to the cerebellum may lead to the impairment of voluntary movements or motor functions in the patient. The function of the hypothalamus is the maintenance of temperature, appetite, sex drive, heart rate, and blood pressure; therefore, the patient may have loss of libido and impaired thermoregulation when there is damage in the hypothalamus. The function of the cerebral cortex is to govern thought processes, memory, reasoning, and sensation; therefore, the patient with cerebral cortex injury or damage may have complete or partial loss of memory.
A patient reports a sudden and severe throbbing headache and right arm weakness. The nurse notices that the patient has facial drooping and stuttered speech. The MRI reports reveal the development of an atherosclerotic plaque formation in the middle cerebral artery. What condition in the patient could be associated with these findings?
Thrombotic stroke A sudden and severe throbbing headache, arm weakness, and facial drooping indicate a cerebrovascular accident (CVA). The patient who is experiencing a CVA may also have difficulty in speaking. Atherosclerosis involves the formation of plaque on the inner walls of the arteries. This plaque may rupture and form a thrombus, which blocks the blood vessels of the brain, resulting in a thrombotic stroke. The patient with a silent stroke may not experience any symptoms of the stroke. Embolic stroke occurs due to the presence of an embolus or a movable clot in the blood vessels. This is common in the patients with atrial flutter or fibrillation. Hemorrhagic stroke may occur when there is bleeding from a weakened artery of the brain.
Which type of basic reflex includes the pupillary response and accommodation?
Visceral reflex There are four types of basic reflexes: the deep tendon reflexes, superficial reflexes, visceral reflexes, and pathologic reflexes. The pupillary response to light and accommodation falls under the category of visceral reflexes. While assessing this reflex, the nurse shines a penlight in the patient's eye and checks if the pupils constrict immediately. The knee jerk falls under the category of a deep tendon reflex. Superficial reflexes include the corneal reflex and the abdominal reflex. Pathologic reflexes are abnormal and may indicate a disease; these reflexes include the Babinski reflex and the Kernig reflex.
The nurse asks the patient to close the eyes and then places a paper clip on the patient's palm. The patient is asked to recognize the object. Which test is the nurse performing?
stereognosis test The stereognosis test determines the patient's ability to recognize familiar objects by feeling their forms, sizes, and weights without seeing them. In graphesthesia, a number is traced on the skin to test the patient's ability to "read" it. Graphesthesia is a good measure of sensory loss if the patient cannot make the hand movements that are needed for stereognosis. Such a problem may occur with arthritis. The nurse simultaneously touches both sides of the patient's body at the same point to perform the extinction test. Normally, both sensations are felt. The ability to recognize only one of the stimuli occurs with a sensory cortex lesion. The stimulus is extinguished on the side opposite to the cortex lesion. The discrimination test measures the discrimination ability of the sensory cortex.
