Neurologic and Sensory Systems Level 1 Questions

A nurse is caring for a client with Guillain-Barré syndrome. The nurse should prepare the client for what essential care related to rehabilitation? A. Physical therapy B. Speech exercises C. Fitting with a vertebral brace D. Follow-up on cataract progression

A. Physical therapy Rational: Rehabilitation needs for a client with Guillain-Barré syndrome focus on physical therapy and exercise for the lower extremities because of muscle weakness and discomfort. A client with Guillain-Barré syndrome does not need speech or swallowing exercises. A client with Guillain-Barré syndrome does not need vertebral support. Problems with cataracts are not associated with Guillain-Barré syndrome.

A client is admitted to the emergency department with head and chest injuries sustained in a motor vehicle accident. What clinical findings indicate that the client is responding to medical intervention and is ready to be transferred from the emergency department to a critical care unit? A. Stable vital signs and pain B. Pale and alert but restless C. Increasing temperature and apprehension D. Fluctuating vital signs and drowsy but easily roused

A. Stable vital signs and pain Rational: Stable vital signs are the major indicators that transfer will not jeopardize the client's condition. Although complaints of pain are a concern, they do not place the client in physiological jeopardy. Restlessness and pallor may be early signs of shock; the client needs further assessment. An increasing temperature is a sign of increasing intracranial pressure; the client should not be transferred at this time. The vital signs are not stabilized; therefore transfer at this time is contraindicated.

During the neurologic assessment of a client with a tentative diagnosis of Guillain-Barré syndrome, what does the nurse expect the client to manifest? A. Diminished visual acuity B. Increased muscular weakness C. Pronounced muscular atrophy D.Impairment in cognitive reasoning

B. Increased muscular weakness Rational: Muscular weakness with paralysis results from impaired nerve conduction because the motor nerves become demyelinated. Diminished visual acuity usually is not a problem; motor loss is greater than sensory loss, with paresthesia of the extremities being the most frequent sensory loss. Demyelination occurs rapidly early in the disease, and the muscles will not have had time to atrophy; this can occur later if rehabilitation is delayed. Only the peripheral nerves are involved; the central nervous system is unaffected.

After performing an otoscopic examination on a client who reports a decrease in hearing acuity, the primary healthcare provider diagnoses the condition as otitis media. Which assessment finding supports the diagnosis? A. Nodules on the pinna B. Redness of the eardrum C. Lesions in the external canal D. Excessive soft cerumen in the external canal

B. Redness of the eardrum Rational: Many conditions are associated with a decrease in hearing acuity. One such condition is otitis media. This condition is diagnosed by redness of the eardrum observed during the otoscopic examination. Nodules on the pinna may be an indication of rheumatoid arthritis, chronic gout, or basal or squamous cell carcinoma. Lesions in the external canal may cause a decrease in hearing acuity but not the manifestation of otitis media. Excessive soft cerumen in the external canal impacts the hearing acuity but not the manifestation of otitis media.

Which hearing disorder is most common in women? A. Tinnitus B. Hyperacusis C. Otosclerosis D. Meniere's disease

C. Otosclerosis Rational: Gender of the client may also influence the conditions associated with hearing loss. Women are at a higher risk of otosclerosis compared to men. Both men and women are equally at risk of some hearing loss due to conditions such as tinnitus and hyperacusis. Meniere's disease is common in men compared to women.

A client has left hemiplegia because of a cerebrovascular accident (CVA, "brain attack"). What can the nurse do to contribute to the client's rehabilitation? A. Begin active exercises. B. Make a referral to the physical therapist. C. Position the client to prevent contractures. D. Avoid moving the affected extremities unless necessary.

C. Position the client to prevent contractors. Rational : To prevent contractures after a brain attack, the client should be positioned in functional alignment, and passive range-of-motion exercises should be performed. Active exercises are impossible with paralyzed limbs. The healthcare provider must request a consult with the physical therapist. Avoiding moving the affected extremities unless necessary will increase contractures and atrophy.

A nurse is monitoring a client who is having a computed tomography (CT) scan of the brain with contrast. Which response indicates that the client is having an untoward reaction to the contrast medium? A. Pelvic warmth B. Feeling flushed C. Shortness of breath D. Salty taste in the mouth

C. Shortness of breath Rational: An untoward response to the iodinated dye used as a contrast is anaphylaxis, a life-threatening allergic response. Anaphylaxis is manifested by respiratory distress, hypotension, and shock; counteractive measures must be instituted. A feeling of warmth or flushing is an expected minor side effect. A salty taste is an expected minor side effect.

what is the nurse assessing when he/she has a pt move their eyes outwards and inwards? A.Color disability B.Peripheral vision C.Intraocular pressure D. Extraocular muscle function

D. Extraocular muscle function Extraocular muscle function is assessed using the corneal light reflex and the six cardinal positions of cranial nerves III, IV, and VI. The Ishihara chart is used to determine colorblindness. Peripheral vision is determined by performing a test called perimetry; the confrontation test can be also be used for peripheral vision. Intraocular pressure is determined by performing tonometry.

A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is priority? A. Urinary output B. Sensation to touch C. Neurologic status D. Respiratory exchange

D. Respiratory exchange Rational: The respiratory center in the medulla oblongata can be affected with acute Guillain-Barré syndrome because the ascending paralysis can reach the diaphragm, leading to death from respiratory failure. Although urinary output, sensation to touch, and neurologic status are important, none of them are the priority.