Neurological Assessment

To evaluate a client's cerebellar function, a nurse should ask:

"Do you have any problems with balance?"

The nurse is preparing a client for a neurological examination by the physician and explains tests the physician will be doing, including the Romberg test. The client asks the purpose of this particular test. The correct reply by the nurse is which of the following?

"It is a test for balance."

The anatomy instructor is discussing the central nervous system. A student asks where the cerebral cortex is located. What should the anatomy instructor answer?

"It is located on the surface of the cerebrum."

A nurse is preparing a client for lumbar puncture. The client has heard about post-lumbar puncture headaches and asks how to avoid having one. The nurse tells the client that these headches can be avoided by doing which of the following after the procedure?

"Remain prone for 2 to 3 hours."

A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following?

"The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid."

The nurse is assessing the client's mental status . Which question will the nurse include in the assessment?

"Who is the president of the United States?"

Which of the following neurotransmitters are deficient in myasthenia gravis?

Acetylcholine

Which term refers to the loss of ability to recognize objects through a particular sensory system; may be visual, auditory, or tactile

Agnosia

Which term refers to the inability to coordinate muscle movements, resulting difficulty walking?

Ataxia

A client is scheduled for an EEG. The client inquires about any diet-related prerequisites before the EEG. Which diet-related advice should the nurse provide to the client?

Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours before the test

A patient who has suffered a stroke is unable to maintain respiration and is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe?

Brain stem

The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve?

CN I

What part of the brain controls and coordinates muscle movement?

Cerebellum

If a client has a lower motor neuron lesion, the nurse would expect to observe which manifestation upon physical assessment?

Decreased muscle tone

Which term refers to a method of recording, in graphic form, the electrical activity of a muscle?

Electromyography

A client has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important postprocedure nursing intervention should be performed to ensure the client's maximum comfort?

Encourage the client to drink liberal amounts of fluids

Which safety action will the nurse implement for a client receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)?

Ensure that no client care equipment containing metal enters the room where the MRI table is located.

The trochlear nerve controls which function?

Eye muscle movement

Which cerebral lobes is the largest and controls abstract thought?

Frontal

Which lobe of the brain is responsible for concentration and abstract thought?

Frontal

A patient sustained a head injury during a fall and has changes in personality and affect. What part of the brain does the nurse recognize has been affected in this injury?

Frontal lobe

Cranial nerve IX is also known as which of the following?

Glossopharyngeal

A male client is scheduled for an electroencephalogram (EEG). When the nurse caring for the client is preparing him for the test, the client states that during childhood he was mildly electrocuted but miraculously lived. Therefore, he is quite afraid of going through an EEG. In what ways can the nurse help dispel the client's fear regarding the test?

Inform the client that he will not experience any electrical shock.

What is the function of cerebrospinal fluid (CSF)?

It cushions the brain and spinal cord.

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?

Lateral recumbent, with chin resting on flexed knees

The nurse is caring for a client after lumbar puncture. The client reports a severe headache. Which actions should the nurse complete? Select all that apply.

Maintain the client on bed rest. Administer fluids to the client. Administer analgesic medication.

The nurse 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

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?

Occipital

Which cranial nerve is responsible for muscles that move the eye and lids?

Oculomotor

The pre-nursing class is learning about the nervous system in their anatomy class. What part of the nervous system would the students learn is responsible for digesting food and eliminating body waste?

Parasympathetic

Symptoms

Sx: Overall appearance (posture, movement, affect, LOC) Signs of pain, seizures, dizziness/vertigo, visual disturbances, muscle weakness, abnormal sensations (paraesthesia) Numbness, tingling, syncope/vertigo, loss of balance, weakness Personal and family history: CVA, muscular dystrophy, epilepsy, tourettes, 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.

The nurse is performing a neurological assessment of a client who has sustained damage to the frontal cortex. Which of the following deficits will the nurse look for during assessment?

The inability to tell how a mouse and a cat are alike

A client is scheduled for standard EEG testing to evaluate a possible seizure disorder. Which nursing intervention should the nurse perform before the procedure?

Withhold anticonvulsant medications for 24 to 48 hours before the exam

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

A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects in the body systems, the nurse anticipates that the liver will:

convert glycogen to glucose for immediate use.

After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an:

evaluation of the corneal reflex response.

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. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit?

occipital

The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse should respond by describing the action of the:

sympathetic nervous system.

A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in

thought content.