NU272 HESI Prep: Med-surg Neurologic and Sensory

Which cranial nerve would the nurse assess further if the client cannot close the right eye?

Seventh - Lesions that affect the seventh cranial (facial) nerve cause paralysis of eyelids; it controls the eye blink. The vagus is the tenth cranial nerve and innervates the pharynx and thoracic and abdominal viscera in addition to the heart. The trochlear nerve, or fourth cranial nerve, is concerned with eye movements. The optic nerve, or second cranial nerve, is concerned with vision; lesions result in visual field defects and loss of visual acuity.

Which medication is a beta-adrenergic blocker used to reduce intraocular pressure?

Timolol - Glaucoma is manifested by increased intraocular pressure. Timolol is a beta-adrenergic blocker used in the treatment of glaucoma. Carbachol is a cholinergic agonist used to treat glaucoma. Travoprost is a prostaglandin agonist, and apraclonidine is an adrenergic agonist used in the treatment of glaucoma.

In which order would the nurse perform assessments to determine the client's neurological status?

1) speak in a normal voice 2) speak in a loud voice 3) shake the client gently 4) apply painful stimuli - The assessment of neurological status should start with speaking to the client in a normal voice. If the client does not respond, the nurse would speak loudly. If the client does not respond to this, the nurse would gently shake the client. The degree of shaking should be similar to that used in waking a child. If the client does not respond to this, painful stimuli can be applied.

A 50-year-old client has difficulty communicating because of expressive aphasia after a cerebrovascular accident (CVA, also known as a "brain attack"). When the nurse inquired about the client's feelings, the spouse responded. Which communication strategy would the nurse use to address this behavior?

Acknowledge the spouse, but look at the client for a response. - The client must have the opportunity to practice language skills; family participation must be accepted and recognized. The spouse should be included and involved in the client's care. Asking the wife how she knows the client's feelings, instructing the wife to let the client answer for himself, and returning to speak with the client when the wife leaves, demeans the spouse and cuts off communication.

A back brace is prescribed for a client who had a laminectomy. Which information would the nurse include in the client's teaching plan?

Apply the brace before getting out of bed. - Applying the brace before getting out of bed is done while in the supine position before the body is subjected to the force of gravity in the vertical position; anatomical landmarks are easier to locate for correct application of the brace, and intraabdominal organs have not shifted toward the pelvic floor via gravity. Using the brace when the back feels tired is unsafe; it should be worn the entire day for support. A firm mattress or bed board should be obtained rather than a soft mattress to maintain adequate back support. Twisting exercises are contraindicated because they exert excessive pressure on the operative site.

Which injury is consistent with a client who has blood draining from the left ear and rhinorrhea after a motor vehicle crash?

Basilar fracture - A fracture at the base of the cranium can tear meninges, causing nasal leakage of cerebrospinal fluid (rhinorrhea) and bleeding from the ear. A bruise will not cause these responses. A severe jarring of the brain will not cause these responses. A nose fracture will not produce a clear drainage, and the ears will not be draining.

A client asks the nurse what causes Parkinson disease. Which description of pathology would the nurse provide in response to the client?

Degeneration of neurons of the basal ganglia - Parkinson disease involves destruction of the neurons of the substantia nigra, reducing dopamine. The cause of this destruction is unknown. Disintegration of the myelin sheath is associated with multiple sclerosis. Breakdown of upper and lower motor neurons is associated with Lou Gehrig disease, or amyotrophic lateral sclerosis. Reduced acetylcholine receptors at synapses are associated with myasthenia gravis.

Which assessment finding would the nurse document in the client's health record as a positive Romberg test?

Inability to stand with feet together when eyes are closed - The Romberg test evaluates proprioception. A client is asked to close the eyes when standing. If balance is lost after the client's eyes are closed, a positive Romberg test suggests that there is a sensory cause. Fanning of toes when the sole of the foot is firmly stroked is a positive Babinski reflex that is indicative of corticospinal pathology in an adult. Dilation of pupils when focusing on an object in the distance is accommodation, a normal finding. Movement of eyes toward the opposite side when the head is turned is the oculocephalic or oculovestibular reflex, a normal finding.

Which finding would the nurse anticipate in the health history of a client who has open-angle (chronic) glaucoma?

Loss of peripheral vision - Increased intraocular pressure damages the optic nerve, interfering with peripheral vision. Flashes of light may be associated with a detached retina. There is difficulty in adjusting to darkness, not an intolerance to light. Seeing floating specks is not specific to glaucoma.

Which hearing disorder is more common in women than in men?

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

The nurse completes an admission assessment on a client who is diagnosed with myasthenia gravis. Which clinical finding would the nurse expect to identify?

Difficulty swallowing saliva - Facial muscles innervated by the cranial nerves often are affected; dysphagia, ptosis, and diplopia are present. Myasthenia gravis is a neuromuscular disease with altered neuromuscular junction and receptors, not central nervous system symptoms (problems with cognition). Intention tremors of the hands are associated with multiple sclerosis. Nonintention tremors of the extremities are associated with Parkinson disease.

The family members of a client who has expressive aphasia ask how they can help the client regain speech function. Which action would the nurse recommend to the family?

Encourage the client to speak while allowing time to respond. - In addition to the extent of injury, a factor in relearning speech is the client's motivation and effort. The more the client attempts to talk, the more likely speech will progress to its optimum level; relearning is a slow process. Clients with aphasia are not deaf. Although the nurse would instruct the family to approve and support the client's efforts to communicate, this support should be for the effort, not for correct communication. Telling the client to use the correct words when speaking will create frustration and may anger the client.

During the neurological assessment of a client with a tentative diagnosis of Guillain-Barré syndrome, which clinical finding would the nurse expect the client to manifest?

Increased muscular weakness - 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.

Which factor increases the risk of respiratory complications in clients with myasthenia gravis?

Ineffective coughing - Weakened muscles result in ineffective coughing; secretions are retained and provide a medium for bacterial growth. The airways are not narrowed. Immune mechanisms are not impaired directly. Viscosity of secretions depends on fluid intake and humidity.

The nurse reviews the diagnostic reports of a client and discovers that the client has an injury to cranial nerve VII. Which condition would the nurse observe upon assessment?

Inhibition of tear production - Injury to cranial nerve VII mainly leads to inhibition of tear production, a condition called keratoconjunctivitis sicca or dry eye syndrome. Any impairment to cranial nerve II may affect peripheral and central vision. Cranial nerves III, IV, and VI affect eye movement. Any injury to these nerves may affect eye movement. The function of cranial nerve III is constriction of the pupil. Any injury to this nerve may lead to impairment of pupil constriction.

A client is diagnosed with hyperopia and has insufficient corneal thickness for a LASIK flap. Which surgical procedure would the nurse anticipate being most likely performed by the primary health care provider in this condition?

Photorefractive keratectomy (PRK) - PRK is suitable for clients who have insufficient corneal thickness and have hyperopia. In this procedure the epithelium is removed and the laser sculpts the cornea to correct the refractive error. Phakic intraocular lenses are referred to as "implantable contact lenses"; they are implanted without removing the eye's natural lens. These are used for clients with a high degree of myopia or hyperopia. A refractive intraocular lens is an implant used for clients with a high degree of myopia or hyperopia. It involves removal of the client's natural lens and implantation of an intraocular lens. In LASIK a laser or surgical blade is used to create a flap in the cornea.

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?

Position the client to prevent contractures. - To prevent contractures, 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 health care provider must request a consult with the physical therapist. Avoiding moving the affected extremities unless necessary will increase contractures and atrophy.

When assessing a client with a diagnosed "brain attack" (cerebrovascular accident [CVA]), the nurse evaluated the baseline vital signs of pulse rate of 78 beats per minute (bpm) and a blood pressure (BP) of 120/80 mm Hg. Which changes in the baseline vital signs indicate an increasing intracranial pressure (ICP)?

Pulse 50 bpm and BP 140/60 mm Hg - increased ICP → decreased HR and increased BP.. Evidence of an increasing intracranial pressure is a widening of pulse pressure and a decreased pulse rate; the changes from baseline vital signs to a pulse of 78 bpm and a BP of 140/60 mm Hg meet the criteria. The remaining vital signs do not meet the criteria: Pulse 56 bpm and BP 130/110 mm Hg, pulse 60 bpm and BP 126/96 mm Hg, and pulse 120 bpm and BP 80/60 mm Hg do not meet these criteria.

A friend transports an adult client to the emergency department and states, "All of us were partying at a club, and all of a sudden my friend collapsed." The client's vital signs are temperature 99.2°F (37.3°C), pulse 152 beats per minute, respirations 32 breaths per minute, blood pressure 163/92 mm Hg. Which action would the nurse implement next, after completing the physical assessment and health history from the client?

Relay the client's status to the health care provider; insert the prescribed intravenous (IV) line. - 3,4-Methylenedioxymethamphetamine (Ecstasy) is an abused drug that has both stimulant and hallucinogenic properties. Stimulants have the ability to cause dehydration by increasing activity and diaphoresis via increased adrenaline release. The client is displaying symptoms of dehydration; the nurse would inform the health care provider and insert the prescribed IV line. Letting the friend stay and reassessing the client in 1 hour are inappropriate; the client's vital signs indicate the need for immediate attention. Placing the client in a private room with a cool cloth on the head is inappropriate; the client's vital signs are indicative of a problem. Performing a neurological assessment every 15 minutes is inappropriate at this time. The client's vital signs indicate a need for immediate medical attention.

Which clinical manifestations indicate a client who sustained head and chest injuries from a motor vehicle accident, responded to medical treatments, and is ready for transfer to a critical care unit?

Stabilized vital signs and complaints of pain - Stable vital signs is the major indicator predicting transfer will not jeopardize the client's condition. Although complaints of pain are a concern, they do not place the client in physiologic 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; delay transfer of the client at this time. Fluctuating vital signs and drowsiness indicate an unstable client with potentially increasing intracranial pressures.

Which health problem history would increase an older adult's risk for experiencing a cerebrovascular accident (CVA, also known as a "brain attack")?

Transient ischemic attacks (TIAs) - TIAs are temporary neurological deficits related to cerebral hypoxia; about one third of the people who have TIAs will have a brain attack (CVA) within 2 to 5 years. Glaucoma, hypothyroidism, and continuous nervousness are not risk factors associated with a CVA.