nyyun928 - Neurologic system

Case Study Questions 1-19 refer to the following case study: Mr. R. age 25, is admitted to the intensive care unit (ICU). He is disoriented to time and place. A co-worker reported that Mr. R. had been hit on the head with a beam 3 hours earlier, causing momentary unconsciousness, but appeared fine until an hour ago, when he became tired and "wasn't making any sense." Physical examination detects a dilated, nonreactive left pupil. The patient's blood pressure is 160/80 mm Hg, his pulse is 80 beats/minute, and his respiratory rate is 16 breaths/minute.

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Case Study Questions 101-109 refer to the following case study: Mrs. G., age 44, is admitted to the ICU with a diagnosis of left frontoparietal astrocytoma. Preparations are made for a craniotomy and excision of the tumor.

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Case Study Questions 110-115 refer to the following case study: Mr. P., a 45-year-old man with a history of seizure disorders, is admitted to the ICU after having a seizure 30 minutes earlier. His family states he takes phenytoin (Dilantin) and phenobarbital at home. His vital signs are stable, but he grimaces only in response to tactile stimuli.

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Case Study Questions 116-120 refer to the following case study: Mr. S., age 67, is discharged from the hospital after treatment for a subarachnoid hemorrhage. He is readmitted 2 weeks later with increasing dementia and ataxia. Hydrocephalus is suspected.

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Case Study Questions 20-34 refer to the following case study: Mr. J, a 23-year-old man who had been weight lifting at a health spa, is admitted to the ICU with complaints of a sudden, explosive headache.

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Case Study Questions 35-43 refer to the following case study. Mr. V is admitted to the ICU after a motor vehicle accident in which the right side of his head hit the windshield A basal skull fracture with right middle meningeal artery damage and a left temporal lobe contusion are detected

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Case Study Questions 44-55 refer to the following case study: Mr. D is admitted to the ICU after a motor vehicle accident. Spinal X-rays confirm a lesion at C5 to C6.

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Case Study Questions 56-68 refer to the following case study: Mrs. G., age 67, is admitted with a diagnosis of glioblastomatype brain tumor. During the physical assessment, she is obtunded. Neurologic assessment reveals pinpoint pupils and an absent corneal reflex. Her serum sodium level is 120 mEqlliter; a secondary diagnosis of syndrome of inappropriate anti-diuretic hormone (SIADH) secretion also is made.

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Case Study Questions 69-77 refer to the following case study: Mr. H., age 55, is admitted to the ICU after suffering a right hemispheric cerebrovascular accident.

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Case Study Questions 78-79 refer to the following case study: Mr. L., age 32, is admitted to the !CU after a fall off a ladder. A myelogram reveals right hemisection of the spinal cord.

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Case Study Questions 80-86 refer to the following case study: Ms. C., age 31, is admitted to the ICU with a diagnosis of suspected meningitis. She complains of a headache and photophobia. A lumbar puncture has been performed, but the causative organism has not been isolated.

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Case Study Questions 87-90 refer to the following case study: Ms. O., a 23-year-old woman with myasthenia gravis, is admitted with pneumonia, increasing weakness, and respiratory insufficiency.

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72. During a neurologic assessment, the nurse watches for signs of uncalhemtatlon. An early indication of this condition is: A. Absent doll's eyes reflex B. Ipsilateral dilated pupil C. Ataxic breathing D. Impaired motor function

72. Correct answer - B Ipsilateral pupil dilation is an early sign of uncal herniation. An expanding lesion of the lateral middle fossa, most often the temporal lobe causes shifting of the inner basal temporal lobe. This area contains the uncus, which is forced through the tentonum as pressure builds. The third cranial nerve and the posterior cerebral artery on the same side of the expanding temporal lobe lesion commonly are caught between the uncus and the tentorium. Ataxic or irregular respirations occur in later stages of herniation. Absence of doll's eyes reflex, a late sign of herniation, indicates brain stem dysfunction. Impaired motor function is a common sign in various neurologic and neuromuscular diseases, such as cerebrovascular accident, multiple sclerosis, and myasthenia gravis.

38. Further assessment may also reveal: A. Otorrhea B. Meningism C. Positive Kemig' s sign D. Hemianopia

Correct answer - A Further assessment of a basal skull fracture may reveal otorrhea or rhinorrhea of CSF. Otorrhea occurs if the dura mater is torn and the tympanic membrane is ruptured, whereas rhinorrhea results if the tympanic membrane is intact. Drainage samples from either site will test positive for glucose.

73. The nurse also assesses the function of the ninth cranial nerve. This nerve 1s: A. A nerve associated with taste sensation B. A motor nerve only C. The hypoglossal nerve D. The innervator of the trapezius muscle

Correct answer - A .Associated with taste sensation, the ninth cranial (glossopharyngeal) nerve has sensory, motor, and parasympathetic functions. The nerve's sensory aspect controls taste sensation and sensation within the phyarynx, which elicits the gag reflex. The nerve's motor portion controls swallowing and movement of the pharynx during phonation. Parasympathetic activities of this nerve include salivation from stimulation of the parotid glands.

9. A goal ofiCP therapy is to maintain: A. Cerebral perfusion pressure above 50 mm Hg B. Mean arterial pressure above 120 mm Hg C. Intracranial pressure below 40 mm Hg D. Diastolic blood pressure below 90 mm Hg

Correct answer - A A goal of therapy in ICP monitoring is to maintain Cpp, the difference between MAP and ICP, above 50 mm Hg. Below that level, impaired cerebral perfusion occurs.

97. Mr. M. has a negative Babinski's reflex. A positive reflex would indicate: A. An upper motor neuron lesion B. A lower motor neuron lesion C. Meningeal irritation D. Peripheral neuropathy

Correct answer - A A positive Babinski's reflex indicates an upper motor neuron lesion. Also called the plantar reflex, it is elicited by stroking the sole with a key or pen up the outer aspect of the foot, curving medially when reaching the ball of the foot. A normal response, or negative Babinski's reflex, is plantar flexion of the large toe or all toes. A positive response is fanning of the toes with dorsiflexion of the large toe, indicating upper motor neuron lesions of the pyramidal tract. A positive response may be normal in children under age 2.

52. Acute spinal cord injury will cause respiratory paralysis at and above which level? A. C4 B. C6 C. C7 D. Tl

Correct answer - A Acute spinal cord injury will cause respiratory paralysis at and above the level of C4; diaphragmatic and intercostal innervation occurs at this level. Mechanical ventilation or pacing of the phrenic nerve, which innervates the diaphragm and intercostal muscles, will be necessary.

5. Which method of determining ICP in a patient with a head injury is unsafe? A. Lumbar puncture B. Epidural monitoring C. Intraventricular catheter D. Subarachnoid screw

Correct answer - A Although a means of measuring intracranial pressure (ICP), lumbar pu ncture is contraindicated if an expanding cerebral mass exists. A lumbar puncture gives accurate pressure readings only if cerebrospina fluid (CSF) is flowing freely within the subarachnoid space. An expanding lesion, adhesions, or constrictions will alter CSF flow, causing an inaccurate pressure reading. Also, with increased ICP, lumbar puncture may reduce spinal pressure, causing brain stem herniation. Epidural monitoring, intraventricular catheters, and subarachnoid screws accurately and safely measure ICP in patients with head injury.

68. The most appropriate basis for discontinuing life support in a comatose patient like Mrs. G. with no hope of meaningful recovery is: A. An agreement reached by the health team and family B. Two flat EEGs C. State law on discontinuing life support D. Physician's order of"no code"

Correct answer - A An agreement between the health team and family is the most appropriate basis for stopping life support in a comatose patient with no hope of meaningful recovery. Discontinuing life support has legal, ethical, and psychosocial implications that can never be fully resolved by legal or procedural methods. Making an informed decision after carefully considering the facts prepares the family for death, reduces needless suffering and cost, diminishes the ambiguity surrounding verbal "no code"orders, and decreases the risk of legal action. The agreement should be carefully documented in the patient's chart and made known to all concerned.

94. Observing Mr. M.'s ability to stand steadily with open eyes assess: A. Cerebellar function B. Proprioceptive function c. Cranial nerve function D. Motor strength

Correct answer - A An inability to stand steadily with the eyes open indicates cerebella dysfunction. Romberg's test, of the ability to stand steadily with the eyes closed, assesses both proprioceptive ability (the awareness of body parts) and cerebellar function. A positive Romberg's test due to proprioceptive problems indicates dysfunction of the posterior ascending column of the spinal cord, which transmits sensory and proprioceptive information to the brain.

84. Which assessment finding is not associated with meningeal irritation? A. Babinski's reflex B. Brodzinski's sign C. Kernig' s sign D. Nuchal rigidity

Correct answer - A Babinski's reflex, which is not associated with meningeal irritation, indicates pyramidal tract damage, an alteration in the motor tracts of the brain.

59. With a lesion in this area, the nurse would most likely assess Mrs. G. for the development of which respiratory pattern? A. Regular, rapid, deep ventilations B. Irregular deep and shallow breathing with irregular periods of apnea C. Regular breathing at a rate of 6/minute D. Cyclical deep rapid and slow shallow breathing followed by periods of apnea

Correct answer - A Central neurogenic hyperventilation, which are regular rapid, deep ventilations, may be assessed in the patient with a lesion of the pons. Biot's respirations, also known as ataxic breathing, is regular deep and shallow breathing with irregular periods of apnea. This pattern of breathing is associated with brainstem compression. Bradypnea, or slow breathing, usually occurs with an abrupt increase in intracranial pressure or narcotic overdosage. Cheyne-Stokes respiration, or cyclical deep rapid and slow shallow breathing followed by periods of apnea, is associated with lesions of the cerebral hemispheres.

116. Which type of hydrocephalus is suspected in Mr. S? A. Communicating B. Noncommunicating C. Normal-pressure D. Excessive cerebrospinal fluid (CSF) production

Correct answer - A Communicating hydrocephalus occurs from an obstruction outside the ventricles, such as decreased absorption in the subarachnoid space. Noncommunicating or obstructive hydrocephalus occurs from an obstruction within the ventricular system. Excessive cerebrospinal fluid production may occur with a tumor of the choroid plexus. Dilated ventricles with an unknown cause occurs in normal-pressure hydrocephalus.

12. Increased ICP is best relieved by which nursing intervention? A. Elevating the head of the bed 30 degrees B. Providing auditory stimulation to decrease sensory deprivation C. Increasing oxygenation through postural drainage and suctioning D. Sedating the patient with morphine sulfate, as needed

Correct answer - A Elevating the head of the bed 30 degrees enhances venous drainage by gravity, reducing ICP. Auditory stimuli, postural drainage, and suctioning should be avoided because they increase ICP. Morphine sulfate should not be used for sedation because it causes respiratory depression, which raises ICP if hypoxemia and hypercapnia result.

78. Mr. L.'s myelogram suggests: A. Brown-Sequard syndrome B. Anterior cord syndrome C. Partial cord syndrome D. Central cord syndrome

Correct answer - A In Brown - Sequard syndrome, damage is located on one side of the spinal cord. As a result, complete motor paralysis occurs on the same (ipsilateral) side, with nearly complete loss of pam and temperature sensations on the opposite (contralateral) side below the lesion. In anterior cord syndrome, damage caused by a forward dislocation or compression injury is mainly concentrated in the cord's anterior aspect. Complete motor paralysis usually occurs below the lesion with complete loss of pain and temperature sensations. In central cord syndrome, injury usually is caused by hyperextension of the cervical spine with compression, resulting in greater motor loss to the arms than to the legs. Partial cord syndrome does not exist.

75. In assessing consciousness, the nurse begins by using: A. Auditory stimulation B. Tactile stimulation C. Light pain D. Deep pain

Correct answer - A In assessing consciousness, the nurse begins by using auditory stimuli, usually by speaking to the patient, and evaluates level of consciousness by observing the response. When any stimulation is provided, one should begin with the minimal amount necessary to evoke a response.

42. Mr. V. is least likely to lose awareness of: A. Person B. Place c. Time D. Memory

Correct answer - A In neurologic disease, the patient is least likely to lose awareness of person, which usually indicates psychosis. Even in the most severe neurologic diseases, the patient who is conscious retains knowledge of the self.

83. The best method to assess Ms. C. for meningeal irritation is to: A. Flex the leg at the hip and knee; then straighten the knee and watch for pain and resistance B. Stroke the side of the sole and watch for dorsiflexion of the great toe C. Check the temperature; a reading of 102°F. (38.9°C.) indicates meningeal irritation D. Check for papilledema

Correct answer - A Kemig's and Brodzinski's signs indicate meningeal irritation. Kemig's sign is elicited by flexing the upper leg at the hip to a 90-degree angle and then attempting to extend the knee. With meningitis, pain and spasm of the hamstrings occur when an attempt is made to extend the knee. Brodzinski's sign is positive when both legs flex at the hip and knees after passive flexion of the head and neck onto the chest. A stiff neck (nuchal rigidity) and photophobia are other symptoms of meningeal irritation.

106. The most reliable index of Mrs. G.'s neurologic condition is: A. Level of consciousness B. Pupillary responses C. Nystagmus D. Inward deviation of the eyes

Correct answer - A Level of consciousness is the most important factor in neurologic assessment of a patient. It is the earliest and most sensitive of indicators, providing information about changes in neurologic status.

70. Loss of motor function in the left arm and leg may indicate a lesion in the: A. Pyramidal tract of the right hemisphere B. Spinocerebellar tract C. Motor nerve fibers in the anterior horn of the spinal cord D. Spinal cord at C7

Correct answer - A Loss of left arm, and leg motor function may indicate a lesion in the pyramidal tract of the right hemisphere. The lateral corticospinal(pyramidal) tract is the most important upper motor neuron tract Damage to it causes contralateral motor loss.

64. Mrs. G.'s neurologic status deteriorates and she begins to have seizures characterized by repetition of inappropriate acts (automatisms). This seizure type is known as: A. Partial complex B. Absence c. Partial motor D. Myoclonic

Correct answer - A Partial complex seizures (also called psychomotor or temporal lobe seizures) are characterized by repetition of inappropriate acts. These acts - called automatisms - may include lip smacking, grimacing, or chewing and are sometimes mistaken for psychotic behaviors. Absence (petit mal) seizures are more likely to occur in childhood and consist of a sudden loss of awareness, but consciousness is retained. Partial motor (Jacksonian) seizures are focal seizures characterized by jerking movements up or down on extremity. Myoclonic seizures brief contractions of certain muscles, are similar to the jerking movements that occur during sleep.

86. Patients with bacterial meningococcal meningitis commonly exhibit: A. Petechiae B. Hypothermia C. Nystagmus D. Hypertensive crises

Correct answer - A Petechiae commonly appear in bacterial meningococcal meningitis. Petechiae, rash, purpuric lesions, or ecchymoses develop in about 50% of patients. Also common are symptoms of fever, headache lethargy, confusion, irritability, and stiff neck.

67. The caloric test: A. Assesses vestibular nerve function B. Is also called the oculocephalic reflex C. Is abnormal if nystagmus is elicited D. Assesses the hunger and satiety centers of the hypothalamus

Correct answer - A The caloric test assesses vestibular function of the eighth nerve. Also known as the oculovestibular reflex, it is performed by instilling ice water into the ear canal. A normal response is nystagmus and vertigo. An abnormal response is conjugate deviation of the eyes to the irrigated ear, indicating brain stem compression.

6. Mr. R. is examined for signs of increased ICP. Which cranial nerve is surrounded by cerebrospinal fluid, providing information about pressure within the brain? A. Optic nerve B. Vagus nerve c. Oculomotor nerve D. Trigeminal nerve

Correct answer - A The optic (second cranial) nerve is bathed in CSF and contains arteries and veins. Thus, funduscopic retina examination reveals much about pressure within the brain, because the retina is the optic nerve ending. Congestion of retinal blood vessels and swelling of the optic head are signs of increased ICP.

28. The parietal lobe is the brain area responsible for: A. Sensory interpretation B. Speech C. Vision D. Emotional responses

Correct answer - A The parietal lobe, the area of the brain controlling sensory interpretation, is at the top posterior portion of the head, between the frontal and occipital lobes. Each hemisphere receives sensory impulses from the opposite side of the body. These sensations include pain; proprioception; heat; cold; recognition of qualities of objects, such as size, shape, and texture, and interpretation of the written word.

20. The presenting history and symptoms indicate: A. Subarachnoid hemorrhage B. Epidural hematoma C. Basal skull fracture D. Brain stem contusion

Correct answer - A The patient is most likely experiencing a subarachnoid hemorrhage caused by an arteriovenous malformation brought on by strenuous activity. Epidural hematoma, basal skull fracture, and brain stem contusion are caused by traumatic injuries.

113. The seizures continue, so the physician administers phenytoin inravenously. Which of the following actions is essential? A. Placing the patient on a cardiac monitor during administration B. Obtaining serum phenytoin levels immediately after administration C. Administering the drug in a dextrose solution D. Administering the drug at a rate no faster than 500 mg/minute

Correct answer - A The patient should be placed on a cardiac monitor and carefully observed. Rapid administration of phenytoin depresses the myocardium and can cause cardiac arrest. Obtaining a level before administration - because the patient was taking this medication at home - provides the physician with baseline levels and prevents possible toxicity. I.V. phenytoin must be given in a saline solution no faster than 50 mg/minute.

80. The meningeal layer that adheres to the sulci and gyri of the brain is the: A. Pia mater B. Sella turcica c. Arachnoid mater D. Dura mater

Correct answer - A The pia mater, the meningeal layer that adheres to the sulci and gyri of the brain, is rich in blood, which it provides to the brain. Its folds form the choroid plexus that produce cerebrospinal fluid (CSF), and it also nourishes the spinal cord cells. The arachnoid layer is the meninges' middle layer, which is in contact with venous blood. Arachnoid villi, finger-like projections of arachnoid mater through the dura mater and into the venous sinuses, regulate resorption of CSF into the venous system. The outer, or dura, layer controls venous drainage by forming veous sinuses. The dura mater also supports structure of the brain. The sella turcica is a bone in the frontal area not a meningeal layer.

56. Which part of the brain controls sleep and wakefulness? A. Reticular activating system B. Cerebral cortex C. Limbic system D. Basal ganglia

Correct answer - A The reticular activating system (RAS) controls sleep and wakefulness. A diffuse network of neurons in the medulla, pons, and midbrain, it controls the state of consciousness. During sleep, RAS activity is diminished, whereas its stimulation causes wakefulness. Almost any sensory impulse can stimulate wakefulness through the arousal reaction.

90. Which statement about myasthenia gravis is true? A. Treatment may include immunosuppressive therapy B. Cholinergic crisis is precipitated by infection, trauma, stress, or surgery c. Myasthenia gravis results from decreased cholinesterase D.Diagnosis is made if improvement occurs after I.V. administration of atropine sulfate

Correct answer - A Treatment of myasthenia gravis may include immunosuppresive drugs, such as steroids, or experimental use of cytotoxic drugs, such as Imuran and Cytoxan. An autoimmune disease, myasthenia gravis is characterized by development of antiacetylcholine receptor antibodies that destroy acetylcholine and cause muscle weakness. Therapy is aimed at breaking down cholinesterase - the enzyme that eliminates acetylcholine- by administering an anticholinesterase such as Mestinon or at suppressing receptor antibody formation (immunosuppression). Diagnosis is made if symptoms temporarily improve after intra-venous injection of Tensilon, a rapid-acting anticholinesterase. Excessive amounts of anticholinesterase may precipitate cholinergic crisis, causing muscle weakness and respiratory paralysis. This is reversed by administering atropine - the antidote for an anticholinesterase. Myasthenic crisis, treated by an anticholinesterase, also induces muscle weakness, but this is a result of too little anticholinesterase or of stress, trauma, infection, surgery, or pregnancy.

91. Which statement about gray or white matter is most accurate? A. White matter contains myelinated fibers B. Gray matter is outside white matter in the spinal cord C. White matter in the spinal cord contains preganglionic fibers ol the autonomic nervous system D. White matter forms an "H' pattern in the spinal cord

Correct answer - A White matter contains both myelinated and unmyelinated fibers, with the myelin giving white matter its color. In the cerebrum, the white matter forms the inner layer, and the gray matter forms the outer layer. White matter consists of the association and projection pathways, and gray matter consists of unmyelinated fibers, cell bodies, and the nuclei of thalamus, hypothalamus, and basal ganglia. However, in the spinal cord, white matter becomes the outer layer, while the gray matter is an H-, or butterfly-shaped, inner layer. White matter in the spinal cord consists of three tracts or pathways. The posterior tract conducts the sensation of pressure, touch, and body position from the same side of the body (it later crosses over in the brain); the anterolateral, or spinothalamic, tract, whose fibers immediately cross over to the opposite side, conducts pain and temperature sensations; and the lateral, or pyramidal, tract transmits motor impulses from the opposite side of the brain. Gray matter of the spinal cord contains motor nerves for voluntary and reflex activity, sensory nerves, and preganglionic fibers of the autonomic nervous system.

41. Appearance of"Raccoon's eyes" indicates: A. A subarchnoid hemorrhage B. An anterior fossa fracture C. An epidural hematoma D. Meningitis

Correct answer - B "Racoon's eyes", accumulation of blood with edema formation around the eyes, results from blood leaking into the orbital cavity and indicates an anterior fossa basal skull fracture.

48. A functioning reflex arc requires all of the following to be intact except the: A. Sensory nerve B. Cortex c. Motor nerve D. Muscle

Correct answer - B A functioning reflex arc does not require an intact cortex. A reflex arc consists of a sensory receptor, a sensory neuron, the spinal cord's anterior horn, the motor nerve, and the muscle or organ responding to the reflex. Because the reflex does not travel up the spinal cord into the brain, reflexes are still present after damage to the cortex.

44. The nurse suspects that Mr. D. has: A. Quadriplegia with intact triceps and biceps and intercostal breathing B. Quadriplegia with gross arm movements and diaphragmatic breathing C. Paraplegia with diaphragmatic breathing D. Diaphragmatic and intercostal breathing with loss of intrinsic hand-muscle power

Correct answer - B A lesion of C5 to C6 would cause paralysis of intercostal respiration, but diaphragmatic respiration would continue without abdominal muscle action because the diaphragm is innervated by C2, C3 and C4. Complete loss of motor power in the trunk and legs (quadriplegia) and bladder and bowel retention occur.

26. Intracranial aneurysms most commonly develop in the: A. Vertebral artery B. Circle of Willis C. Subarachnoid space D. Pituitary gland

Correct answer - B About 60% of intracranial aneurysms develop in the circle of Willis, which is formed by the anastomosis of the internal carotid artery, anterior and posterior cerebral arteries, and anterior and posterior communicating arteries. About 50% of the population has congenital abnormalities at the circle of Willis, with 8% of this population developing intracranial aneurysms because of the many bifurcations of arteries occurring within the circle. These congenital defects usually do not appear until midlife, when hypertension and arteriosclerosis have taken their toll on the weakened artery, causing it to balloon or rupture.

25. The angiogram reveals rupture of an intracranial aneurysm in the parietal area. Blood is delivered to that area by the: A. Vertebral arteries B. Internal carotid arteries c. Cerebeller arteries D. Basilar arteries

Correct answer - B About 75% of blood to the brain is supplied by the internal carotid arteries, which supply the anterior portion of the brain (the frontal, temporal, and parietal areas). The vertebral arteries, which originate off the subclavian artery, supply the posterior portion of the brain (the occipital area), dividing into two branches and then later reuniting to form the basilar artery.

37. This patient may have injured the: A. Oculomotor nerve B. Olfactory nerve C. Optic nerve D. Ophthalmic nerve

Correct answer - B Basal skull fractures may cause nerve injuries. Injury to the olfactory (first cranial) nerve is common, causing loss of the sense of smell (anosmia). Other cranial nerve injuries include those to the facial nerve (seventh), causing ipsilateral facial paralysis, and the acoustic nerve (eighth), leading to hearing or equilibrium disturbances.

36. Mr. V. should be assessed for Battle's sign, which is: A. A postconcussion syndrome B. An ecchymosis over the mastoid bone C. Black-and-blue discoloration around the eyes D. A superficial hematoma on the skull

Correct answer - B Battle's sign, bleeding with resultant ecchymosis over the mastoid bone, may take up to 24 hours to develop. It is commonly seen in basal skull fractures involving the middle fossae. A basal skull fracture may involve the anterior, middle, or posterior fossae at the base of the skull.

115. After discharge teaching with Mr. P. regarding phenytoin therapy the nurse evaluates that he correctly understand his medication by which of the following statements? A. "I should avoid alcohol because it makes the dilantin build up in my body" B. "I can take the dilantin in the morning or in the afternoon" C. "I should not make up missed doses" D. "I should take aspirin, rather than actaminophen, for headaches"

Correct answer - B Because phenytoin is absorbed slowly from the gastrointestinal tract, timing of the daily dose can vary, according to patient convenience, and missed doses can be made up. Alcohol inhibits the action of phenytoin, while aspirin potentiates its effects.

32. This patient should be assessed for: A. Battle's sign B. Brudzinski's sign C. Cullen's sign D. Cushing's reflex

Correct answer - B Brodzinski's sign may occur in the patient with subarachnoid hemorrhage. A sign of meningeal irritation, it is elicited by flexing the patient's head onto the chest and watching for hip and knee flexion, an abnormal response. Meningeal irritation occurs in meningitis and subarachnoid hemorrhage.

22. Cerebrospinal fluid (CSF) is formed by the: A. Aqueduct of Sylvius B. Choroid plexus C. Arachnoid mater D. Nodes of Ran vier

Correct answer - B Cerebrospinal fluid (CSF) is formed by the choroid plexus, a net work of capillaries in the pia mater covered by epithelial cells in the brain's lateral, third, and fourth ventricles. Most CSF is formed in the lateral ventricles; a small amount is formed by the regular capillary beds that supply the arachnoid meningeal layer.

13. Cushing's reflex is a: A. Stress ulcer caused by vagal stimulation B. Cardiovascular response to increased ICP C. Compression of the respiratory centers D. Facial grimacc in response to tapping the nose

Correct answer - B Cushing's reflex, a cardiovascular response to increased ICP, includes widening pulse pressure, increasing systolic blood pressure, and bradycardia. Blood pressure is controlled in the medulla; as this is compressed, systolic pressure rises, widening the pulse pressure. The rising systolic blood pressure stimulates baroreceptors in the aortic arch and carotid sinus to lower the heart rate through vagal stimulation. A stress ulcer caused by vagal stimulation is called Cushing's ulcer and typically presents with acute spinal cord injury. Compression of the respiratory centers occurs in brainstem herniation. A facial grimace in response to tapping the nose is called the stout reflex.

31. An ECG shows T -wave inversion. ECG changes accompanying such a neurological disease as Mr. J. has are thought to be caused by: A. Microemboli formation B. Autonomic discharge C. Inflammation D. Coincident heart disease

Correct answer - B ECG changes (such as ventricular dysrhythmias, ST-segment and T-wave changes, and bradycardia) that accompany subarachnoid hemorrhage or cerebrovascular accident may be caused by autonomic discharge. A sympathetic or parasympathetic discharge is thought to occur, although the exact mechanism is unknown. On autopsy, some patients with these diagnoses have myocardial damage that may be caused by autonomic discharge.

96. The cremasteric reflex is absent in Mr. M. This reflex: A. Is a deep tendon reflex B. Is found only in men C. Assesses level of consciousness D. Indicates autonomic dysfunction

Correct answer - B Found only in men, the cremasteric reflex is a superficial, cutaneous reflex elicited by stroking the inner thigh. The reflex is present if the scrotum elevates on the same (ipsilateral) side. Damage to either the upper or lower motor neuron is suspected if this reflex is absent.

14. Conditions that further increase ICP include: A. Hypoxemia, hypercapnia, and alkalosis B. Hypoxemia, hypercapnia, and acidosis C. Hypoxemia, hypocapnia, and alkalosis D. Hypoxemia, hypocapnia, and acidosis

Correct answer - B Hypoxemia, hypercapnia, and acidosis are potent vasodilators as the body attempts to increase oxygen supply to the brain. Cerebral vasodilation causes an increase in brain blood volume and a subsequent rise in ICP.

34. In a subarchnoid hemorrhage, immediately after initial bleeding or surgical repair, the patient is most at risk for: A. Rebleeding B. Vasospasm C. Diabetes insipidus D. Pulmonary emboli

Correct answer - B In a subarachnoid hemorrhage, immediately after initial bleeding or surgical repair, the patient is most at risk for vasospasm, or constriction of cerebral arteries. Its cause is unknown but may be irritation or sympathetic discharge. Symptoms include hemiparesis, visual disturbances, seizure activity, decreasing level of consciousness and, if severe enough, cerebral ischemia or infarction. Rebleeding from clot dissolution typically occurs 7 to 10 days after the initial insult.

40. Injury to the brain area opposite the area of impact in a closed-head lnjury is: A. Ipsilateral injury B. Contrecoup injury C. Battle's sign D. Epidural hematoma

Correct answer - B Injury to the brain area opposite the impact in a closed-head injury is called a contrecoup injury. A coup injury occurs at the impact site because of the object's impact. A contrecoup injury occurs as brain tissue rebounds from the impact, hitting the opposite side of the brain. Thus, two sites of the brain are injured.

85. Which nursing action is not implemented for a patient who has just been diagnosed as having viral meningitis? A. Instituting seizure precautions B. Instituting isolation precautions C. Monitoring temperature frequently D. Controlling increased intracranial pressure

Correct answer - B Isolating the patient with viral meningitis is unnecessary. Correct nursing interventions include frequent temperature monitoring, because fever increases ICP, and maintaining the patient on seizure precautions, because seizure activity is common in central nervous system infection. Monitoring and managing increased ICP are also critical.

69. Damage to the right cerebral hemisphere may exhibit: A. Right hemiparesis B. Left homonymous hemianopia C. Deviation of the eyes to the left D. Right hemiplegia

Correct answer - B Left homonymous hemianopia, or blindness of the left visual field, may occur in right cerebral hemisphere damage. The optic tracts to the right half of each eye, which relay vision from the left visual field, may be damaged. Avoidance of the left visual field, may be damaged. Avoidance of the left visual field may occur, causing the eyes to deviate to the right. Contralateral motor weakness or loss also may occur, resulting in left hemiparesis or hemiplegia.

45. Motor neurons arising from which tract control gross motor movements? A. Pyramidal tract B. Extrapyramidal tract C. Lateral spinothalamic tract D. Posterior tract

Correct answer - B Motor neurons arising from the extrapyramidal tract control gross motor movements and posture. These upper motor neurons course from the cortex to the spinal cord but are mediated by the cerebellum, basal ganglia, thalamus, and reticular formation. Impulses are transmitted to the rubrospinal, vestibulospinal, reticulospinal, and tectospinal tracts in the spinal cord. Upper motor neurons of the pyramidal tract course from the cortex to the internal capsule, then to the pyramids of the medulla, where some fibers cross, and down to the spinal cord. These control fine, skilled motor movements.

105. Postoperatively, the nurse evaluates which finding as evidence that Mrs. G. is developing a complication of surgery? A. Serum osmolarity of 295 mOsm/liter B. Urine specific gravity of 1.00 C. Urine output of 100 ml/hour D. Serum sodium of 134 mEq/liter

Correct answer - B Postoperatively, the patient should be assessed for complications of diabetes insipidus caused by interruption of the nerve fibers connecting the hypothalamus and pituitary gland. Antidiuretic hormone is not secreted, resulting in the production of dilute urine. Up to 15 liters of urine per day may be lost. A low specific gravity will be noted, along with signs of fluid volume deficit, such as increased serum osmolarity and increased serum sodium.

47. Spinal reflexes in this patient indicate an intact: A. Upper motor neuron B. Lower motor neuron C. Brainstem D. Thalamus

Correct answer - B Spinal reflexes indicate an intact lower motor neuron, which originates in the spinal cord's anterior horn and ends in a specific muscle fiber. A simple reflex arc occurs when a receptor, such as the patellar tendon, is stimulated, and the impulse is transmitted via a sensory neuron to the spinal cord's anterior horn. The impulse then exits the spinal cord via the lower motor neuron to the muscle, eliciting a knee jerk. The reflex does not travel up the spinal cord, so the functioning of the upper motor neuron or the thalamus as a relay station cannot be established. The brainstem does not transmit motor reflexes.

76. The Glasgow Coma Scale, used to assess neurologic status, measures. A. Pupillary reaction, motor response, and verbal response B. Eye opening, motor response, and verbal response C. Eye opening, vital signs, and verbal response D. Pupillary reaction, motor response, and vital signs

Correct answer - B The Glasgow Coma Scale assigns a numeric value to the patient's ability to open the eyes, respond verbally, and demonstrate motor response to different kinds of stimuli. For a possible total of 15, the points are distributed as follows : eye opening = 1 to 4; motor response = 1 to 6; verbal response = 1 to 5.

77. Mr. H. exhibits decerebrate (extensor) posturing. Which areas of the brain have been injured? A. The cerebrum and cerebellum B. The cerebrum and brain stem C. The hypothalamus and brain stem D. The cerebellum and hypothalamus

Correct answer - B The cerebrum and brain stem have been damaged if decerebrate posturing is evident . Both control motor function. The cerebellum coordinates muscle tone with movement and maintains equilibrium. The hypothalamus does not regulate motor function.

102. The corpus callosum: A. Maintains the structural integrity of the frontal lobe B. Provides communication between the hemispheres C. Provides communication from the cortex to the thalamus D. Forms the cerebrospinal fluid

Correct answer - B The corpus callosum provides communication between the brain's right and left lobes. The largest of the commissures- bands of fibers that interconnect the hemispheres - it allows the two hemisphere to function as a whole, exchanging sensory information, memory, and discrimination. Cutting the corpus callosum blocks information transmission from the dominant hemisphere to the nondominant motor cortex and prevents transmission of visual and proprioceptive information from the nondominant to the dominant hemisphere.

112. Mr. P. develops a continuous generalized seizure, and the physician diagnoses status epilepticus. The drug of choice to control status epilepticus is: A. Pentobarbital B. Diazepam C. Phenobarbital D. Pavulon

Correct answer - B The drug of choice to manage status epilepticus is diazepam , a rapid-acting anticonvulsant with less tendency than other anticonvulsants to produce hypotension.

66. The physician assesses the oculocephalic reflex and performs the caloric test. The oculocephalic reflex is: A. An abnormal reflex when present B. Absent in severe brain stem involvement C. The movement of eyes in the direction the head turned D. An indication of first cranial nerve function

Correct answer - B The oculocephalic reflex (doll's eyes), absent in severe brain stem involvement, normally is elicited by turning the head from side to side with the eyes opened. The eyes move in the direction opposite to which the head is turned. If brain stem damage occurs, the eyes do not move or move in any combination of ways. The reflex may also be abnormal in third cranial nerve dysfunction, which involves external eye movements.

104. During surgery, the anesthesiologist hyperventilates the patient to decrease intracranial pressure. What is the rationale for this action? A. The fast respiratory rate depresses the respiratory center B. Antidiuretic hormone is inhibited to increase diuresis C. Hypocarbia causes vasoconstriction D. Alkalosis stimul ates the blood-brain barri er lo decrease blood flow to the brain

Correct answer - C Hypocarbia, a reduced PC02 from hyperventilation, causes vasoconstriction, thereby reducing blood volume to the brain, and assists in decreasing ICP.

39. A nurse caring for a patient with a basal skull fracture should: A. Instruct him to blow his nose gently B. Prevent the patient from performing Valsalva's maneuver C. Promote coughing and deep breathing D. Institute nasogastric suctioning to prevent vomiting

Correct answer - B The patient with a basal skull fracture should avoid further tearing of the dura by preventing transient increases in ICP; therefore, he must be instructed to avoid coughing and performing Valsalva's maneuver. Also, he should be told to allow fluid to drain freely from the nose rather than blowing it. If rhinorrhea is significant, then a small loose dressing may be applied. Nasogastric tubes, suction catheters, and other objects should not be put into the nose or ears.

16. During a neurologic assessment, a reliable early indicator of the patient's level of consciousness is his ability to: A. Think abstractly B. Open his eyes when addressed C. Squeeze the nurse's fmgers tightly D. Name objects correctly

Correct answer - B The patient's ability to open his eyes when addressed is a reliable early indicator of his level of consciousness. A response to verbal stimuli indicates intactness of higher cortical areas, such as reticular activating system, responsible for wakefulness via the arousal mechanism. An inability to open the eyes when addressed indicates brain stem involvement, hearing loss, or facial paralysis.

3. Diagnostic studies reveal a temporal fracture with a pineal shift. This finding is typically associated with: A. Subdural hematoma B. Epidural hematoma C. Subarachnoid hemorrhage D. Intracerebral hemorrhage

Correct answer - B The temporal fracture, development of a hematoma (which causes a contralateral pineal shift), the ipsilateral fixed pupil, and a deteriorating level of consciousness indicate an epidural hematoma.

103. Preoperative preparation for Mrs. G. would include: A. Initiating a continuous heparin infusion B. Putting on thigh-high, antiembolism stockings C. Administering 0.9% normal saline solution intravenously at 150 ml/hour D. Inserting a nasogastric tube

Correct answer - B Thigh-high, antiembolism stockings are used preoperatively, and up to 2 days postoperatively, to reduce venous stasis and prevent emboli formation. Anticoagulants, such as heparin, are contraindicated because they increase the risk of bleeding. The patient is kept dehydrated to reduce risk of increased intracranial pressure (ICP). A nasogastric tube is not indicated because the patient should be able to resume oral feedings soon after surgery.

17. Two days after admission, the patient suffers a generalized (grand mal) seizure. The seizure phase characterized by contraction and apnea lasting about 1 minute is called the: A. Aura phase B. Tonic phase c. Clonic phase D. Postictal phase

Correct answer - B The tonic phase of a generalized by contraction and apnea, usually begins with a shrill cry as the vocal cords contract with air passing through them. This phase follows the precital (aura) phase, characterized by a seizure prodome, such as irritability, blurred vision, confusion, or focal seizures. The clonic phase follows the tonic phase and is characterized by rhythmic, jerking movements and loud hyperventilations, lasting 2 to 5 minutes. The postictal phase, characterized by a few hours of sleepiness and lethargy, occurs after the seizure ends.

24. A cerebral angiogram is performed on Mr. J. Potential postprocedure nursing diagnoses include: A. Pain related to postprocedure headache B. Sensory-perceptual alteration related to photophobia C. Altered tissue perfusion related to interruption of arterial flow D. Fluid volume deficit related to contrast medium administration

Correct answer - C A potential nursing diagnosis following a cerebral angiogram is altered tissue perfusion related to interruption of arterial flow. Femoral arterial occlusion can result following this study. Hence, distal pulses should be frequently assessed and the leg kept straight for 12 hours. High-Fowler's position should be avoided as this position can compress the femoral artery. This procedure should not routinely cause a headache or photophobia. An adverse renal reaction to contrast medium may result in kidney failure with the development or fluid volume excess.

43. While assessing Mr. V. 's pupillary response, the nurse detects nystagmus. Which of the following statements about nystagmus is true? A. It is always an abnormal finding B. It suggests a spinal cord lesion C. It is analogous to a body tremor D. It refers to unequal pupil size

Correct answer - C Analogous to a body tremor, nystagmus is a rhythmic tremor or the eyeball, normally elicited when the patient watches a rapidly moving object, such as a train. It occurs in damage to the vestibular portion of the eighth cranial nerve, in cerebeller drug toxicity. The tremor is usually faster in one direction than the other and is defined by the faster direction, either right or left.

114. Which situation can occur if l.V. phenytoin is administered by a rapid bolus? A. Ventricular tachycardia B. Supraventricular tachycardia C. Third-degree heart block D. Electromechanical dissociation

Correct answer - C Because phenytoin is a myocardial depressant, third-degree heart block and cardiac arrest are most likely to occur if excessive or rapid doses of I.V. phenytoin are administered.

79. Which of the following clinical findings would be detected in this patient? A. Complete motor, pain, and sensation loss below the level of the lesion B. Greater loss of motor function in the arms than in the legs C. Motor loss on the right side and loss of pain and temperature sensation on the left side below the level of the lesion D. Spastic paralysis below the level of the lesion

Correct answer - C Brown - Sequard syndrome results from trauma or tumor and causes an incomplete transection of the spinal cord. On the side of the transection below the lesion, motor paralysis and sensory loss of vibration and position occur. The corticospinal and posterior column tracts carrying those impulses cross at the level of the medulla, so the loss is on the same (ipsilateral) side. The spinothalamic tract crosses soon after it enters the spinal cord, carrying sensations of pain and temperature. In Brown - Sequard syndrome, loss of pain and temperature sensation occurs on the opposite (contralateral) side. As a result, the side of the body with motor paralysis retains pain and temperature sensations, and the other side retains movement.

11. The ICP monitor waveform becomes progressively elevated. The first-line treatment in acute increased ICP is to administer: A. Aminocaproic acid (Amicar) B. Glucose C. Mannitol D. Barbiturates

Correct answer - C First-line treatment for acute increased ICP is administration of mannitol, an osmotic diuretic that reduces cerebral edema by increasing blood osmolarity. Interstitial fluid shifts into the blood interstitial fluid to decrease osmolarity. Mannitol begins acting rapidly and lasts several hours. If given in concentrations above 20% it must be administered via an in-line I. V. filter because of possible crystallization.

100. A high priority nursing diagnosis to assess Mr. M. for now would be: A. Fluid volume excess B. Sensory-perceptual deficit C. In effective breathing pattern D. Impaired tissue perfusion

Correct answer - C If the ascending muscle weakness continues, Mr. M. is at risk for the development of ineffective breathing patterns as respiratory muscles weaken. Assess for hypoventilation and decreased respiratory excursion.

10. In ICP monitoring, the transducer should be level with the: A. Right atrium B. Foramen magnum C. Foramen of Monro D. Nuchal area

Correct answer - C In ICP monitoring, the transducer should be level with the foramen of Monro - the interventricular foramen connecting the lateral and third ventricles. When the patient is supine, the external landmark for this foramen is midway between the eyebrow's end and the tragus of the ear. Successive readings should be taken with the transducer and the patient in the same position.

88. Neurophysiologically, summation causes: A. Saltatory conduction B. Neurotransmitter secretion c. An action potential D. Myelin formation

Correct answer - C Neurophysiologically, summation is the stimulation of many nerve fibers at one time, which increases the change of creating an action potential, or impulse. The nodes of Ranvier and the myelin sheath control saltatory conduction. Arrival of an impulse at a synapse creates neurotransmitter secretion. Schwann's cells and oligodendroglia control myelin formation in the peripheral and central nervous systems, respectively.

87. The neurotransmitter acetylcholine, which is impaired in myasthenia gravis, normally carries the nervous impulse: A. Up the spinal cord B. Along the muscle C. Across the synapse D. Into the cerebral cortex

Correct answer - C Neurotransmitters, such as acetylcholine, carry an impulse across the synapse - the junction between two nerves or between nerve and muscle. When the impulse reaches the synapse, an excitatory neurotransmitter is secreted, increasing the receptivity of the synapse to the impulse. Inhibitory neurotransmitters decrease the receptivi ty of the synapse for the impulse, preventing the impulse from crossing the synapse.

1. Which diagnostic test should have been performed in the emergency department before Mr. R. was transported to the ICU? A. Lumbar puncture B. Computed tomography (CT) scan C. Cervical spine and skull X-rays D. Cerebral angiography

Correct answer - C Once the patient's vital signs are stabilized in the emergency department, cervical spine and skull X-rays must be evaluated for a cervical spinal cord injury before transporting the patient to the intensive care unit (ICU) or beginning further diagnostic procedures, such as a computed tomography (CT) scan (to pinpoint the area of damage). Cerebral angiography is not indicated because the origin of the problem was trauma rather than a vascular incident. A lumbar puncture is contraindicated in expanding cerebral lesions because the test may cause a brainstem herniation from pressure shifts.

33. The nurse notes that the patient is in a state of extreme extension, with the neck and back arched. This is documented as: A. Decorticate posturing B. Decerebrate posturing C. Opisthotonos D. Nuchal rigidity

Correct answer - C Opisthotonos, extreme extension of the body with the neck and back arched, occurs in patients with tetany or brain stem damage. Decorticate posturing (flexor posturing) occurs in patients with damage to the cortex, thalamus, internal capsule, or basal ganglia; it consists of arm flexion and leg extension. Decerebrate posturing (extensor posturing), seen in brain stem damage, exhibits extension of all extremities, with outward pronation of the wrists and hands. Nuchal rigidity occurs in meningeal irritation and produces pain and stiffness when the patient's head is flexed toward the chest.

108. The evening after surgery, Mrs. G. develops tonic-clonic movements of the right arm and leg, a seizure type called: A. Generalized motor B. Generalized myoclonic C. Partial motor D. Partial complex

Correct answer - C Partial motor seizures are characterized by tonic-clonic movement limited to one side of the body. Generalized motor, or grand mal, seizures produce tonic-clonic movement of the entire body and loss of consciousness, followed by a postictal state of drowsiness. Jerking motions occur in generalized myoclonic seizures. Partial complex seizures are characterized by bizarre behavior with no loss of consciousness, followed by postictal drowsiness and amnesia about the episode.

111. Which nursing action has the highest priority for Mr. P. in a postictal state? A. Obtaining a complete history from the family B. Administering 0.9% normal saline solution intravenously c. Placing the patient on his side and inserting an I.V. line D. Calling the physician and obtaining a suction apparatus at the bedside

Correct answer - C Patent airway maintenance is the foremost nursing goal. Placing the patient in a side-lying position with the head in alignment with the body helps to prevent aspiration. An I.V. line may then be established to administer anticonvulsants.

21. A lumbar puncture is performed. Mr. J is placed in a side-lying, knee-chest position to: A. Prevent further headaches B. Avoid spinal cord injury C. Afford easier access to the spinal canal D. Prevent accidental injury to nearby organs

Correct answer - C Placing the patient in a side-lying, knee-chest position provides easier access to the spinal canal. This position separates the vertebrae in the lumbar region, widening the intervertebral spaces. A lumbar puncture is usually performed in the intervertebral space between L4 and L5.

63. Which statement is true about SIADH? A. Treatment is usually with vasopressin tannate in oil B. It results in hypernatremia C. Pulmonary tumors may be the precipitating cause D. It can result in dehydration, particularly in elderly or unconscious persons

Correct answer - C Pulmonary tumors may precipitate SIADH. Oat cell carcinomas, a type of pulmonary tumor, may inappropriately produce ADH. Other causes of SIADH include cerebrovascular accident, cranial surgery, and intracranial tumors. In these situations, the posterior pituitary gland is stimulated by the hypothalamus to produce excessive ADH and water is reabsorbed, causing hyponatremia. This can result in fluid overload in someone prone to congestive heart failure (CHF). Treatment includes fluid restriction, diuretics, saline replacement, and administration of demeclocycline (Declomycin), an antibiotic that impairs antidiuretic secretion. Diabetes insipidus (DI), causes by a deficiency of ADH, results in hypernatremia and dehydration. Vasopressin tannate in oil, a form of ADH, may be used to treat Dl.

81. The blood-brain barrier: A. Exists throughout the capillary bed of the brain and choroid plexus B. Is impermeable to carbon dioxide C. Is caused by the fusion of endothelial capillary cells D. Attempts to· maintain sterility of the brain

Correct answer - C The blood-brain barrier is produced by fusion of endothelial cells, which causes "tight junctions" at the site of brain capillaries and a relative impermeability to certain substances. The mechanism for determining this impermeability is unknown. The blood-brain barrier exists throughout the choroid plexus and the brain except in the hypothalamus, because it is so involved in water regulation that it must come in contact with more solutes. The blood-brain barrier is most permeable to water, oxygen, and carbon dioxide.

23. Which statement accurately describes characteristics of CSF? A. It is normally yellow B. It is contained in the subdural space C. Its glucose is 60% of blood glucose D. A major portion is distributed in the brain

Correct answer - C The glucose of CSF is 60% of the blood glucose. A high cerebral glucose level is needed to maintain proper neurologic functioning, which is why hypoglycemia can cause permanent brain damage. CSF is normally clear; yellow CSF indicates the presence of old blood - a condition termed xanthochromia- caused by degradation of red blood cells. Although some CSF is contained in the subarachnoid space and four ventricles of the brain, most is contained in the spinal cord.

2. Mr. R. 's history and physical examination suggest which neurologic problem? A. Cerebral concussion B. Expanding lesion on the right side of the brain C. Expanding lesion on the left side of the brain D. Meningeal irritation

Correct answer - C The history and physical examination suggest an expanding lesion on the left side of the brain; the increasing confusion suggests neurologic impairment. However, if an expanding lesion is developing, the ipsilateral (same side) pupil will dilate because the oculomotor nerve is compressed.

15. Mr. R. develops a fever that, after negative culture reports, is diagnosed as a central fever. The brain area that regulates body temperature is the: A. Reticular activating system B. Hippocampus C. Hypothalamus D. Thalamus

Correct answer - C The hypothalamus regulates body temperature and water retention and excretion. In its preoptic and anterior areas, heat-sensitive neurons are stimulated to cause heat loss when body temperature rises. When body temperature falls, these neurons are inhibited, and cold sensitive neurons in the hypothalamus and midbrain are stimulated to initiate shivering. The hypothalamus regulates body water by stimulating thirst and secreting antidiuretic hormone (ADH). When electrolytes become concentrated in the thirst center (the lateral hypothalamus), thirst is stimulated. The hypothalamus also stimulates or inhibits secretion of ADH stored in the posterior pituitary gland in response to dehydration or fluid excess.

57. The neuroglial cells known as oligodendroglia are: A. Found along peripheral nerves B. Star -shaped in nature C. Responsible for myelin formation D. Macrophages

Correct answer - C The neuroglial cells known as oligodendroglia are responsible for myelin formation. Neuroglial cells are the supportive tissue of the nervous system and are classified as astrocytes, oligodendroglia, or microglia. Astrocytes are star-shaped in nature; their function is unknown but may be part of the blood-brain barrier. Oligodendroglia take part in myelin formation only in the central nervous systern; their counterparts, the Schwann cells, perform that function in the peripheral nervous system. Microglia are phagocytes.

35. Mr. V. is likely to develop which condition? A. Subdural hematoma B. Subarachnoid hemorrhage C. Epidural hematoma D. Aneurysm

Correct answer - C The patient is likely to develop an epidural hematoma, which is caused by arterial bleeding. A subdural hematoma results from venous bleeding. A subarachnoid hemorrhage is caused by a ruptured aneurysm, which is a weakening of a vessel wall.

49. Sensory impulses are relayed to the appropriate brain area by the: A. Cerebrum B. Medulla c. Thalamus D. Corpus callosum

Correct answer - C The thalamus relays sensory impulses to the appropriate brain area, conveying all but olfactory impulses to the correct area of the cerebral cortex. Located on either side of the brain's third ventricle, the thalamus also coordinates motor responses and controls brain rhythmicity and emotional affect.

7. An intraventricular catheter is inserted for direct ICP monitoring the next day. An advantage of this monitor is that: A. Infection risk is lessened B. It is easily inserted C. Cerebrospinal fluid (CSF) drainage can occur D. It has the least risk of complications

Correct answer - C Three frequently used devices measure ICP: intraventricular catheter, epidural sensor, and subarachnoid screw. The intraventricular catheter, inserted directly into the lateral ventricle, also allows drainage and sampling of CSF. Although reliable, it is the most difficult to insert and has the most complications - infection and the risk of excess CSF drainage. An epidural sensor sits atop the dura, is easily inserted and carries less infection risk because it doesn't penetrate the meninges. However, CSF sampling cannot be performed. A subarachnoid screw is easily inserted under the dura into the space and carries less infection risk than the intraventricular catheter. It allows sampling, but not drainage, of CSF.

46. Functioning of the spinothalamic tract is determined by: A. Applying a tuning fork to a bony prominence and asking the patient to identify the vibration B. Asking the patient to close both eyes and touch the nose with a finger C. Asking the patient to identify areas stimulated by a pinprick D. Testing the patient's position sense

Correct answer - C To assess spinothalamic tract function, the nurse asks the patient to close both eyes and identify areas stimulated by pinprick. The lateral spinothalamic tract conveys pain and temperature sensation; the anterior spinothalamic tract conveys these as well as light touch and pressure. Identifying vibration and position assesses proprioreceptive sensation; point-to-point testing assesses coordination.

117. Which diagnostic tool is used to document hydrocephalus? A. Lumbar puncture B. Craniotomy C. Angiogram D. Computed tomography (CT) scan

Correct answer - D A computed tomography (CT) scan is used to document hydrocephalus because it visualizes the dilated ventricles.

58. Pinpoint pupils in an obtunded patient may indicate a lesion in the: A. Pituitary gland B. Hypothalamus C. Cerebellum D. Pons

Correct answer - D A lesion or hemorrhage compressing the pons also compresses the oculomotor nerve, constricting the pupils to pinpoint size. Opriate usage may also cause pinpoint pupils from overstimulation or the oculomotor nerve, which controls pupillary constriction. This nerve originates in the midbrain and passes from the brain stem at the upper pons.

61. The brain tumor with the best prognosis is a: A. Meningioma B. Glioblastoma C. Astrocytoma D. Pituitary adenoma

Correct answer - D A pituitary adenoma is the brain tumor with the best prognosis because it is benign, is easily accessible through transphenoidal surgery, and rarely recurs. Meningiomas, although also benign, are less accessible and have a recurrence rate of 25% to 75% within several years. Astrocytomas and glioblastomas are malignant tumors of the glial cells. An astrocytoma's prognosis depends on its grade (I to III) and accessibility. A glioblastoma, sometimes called a grade IV astrocytoma, has the worst prognosis - a 0% survival within 5 years.

19. After the intraventricular catheter is removed, which finding may indicate chronic increased ICP? A. Hypercapnia B. Nystagmus C. Hypotension D. Widening pulse pressure

Correct answer - D A widening pulse pressure may indicate chronic increased ICP. Considered a part of Cushing's reflex, the systolic pressure rises as the medulla is compressed. In patients with more chronic intracranial diseases, such as hydrocephalus, monitoring the pulse pressure for an increase may give a clue to slowly rising ICP.

30. Animocaproic acid (Amicar) is ordered for Mr. J. An appropriate nursing diagnosis to monitor for while infusing this medication would be: A. Decreased cardiac output related to altered cardiac electrical conduction B. Fluid volume deficit related to active gastrointestinal blood loss C. Decreased cardiac output related to allergic reaction D. Impaired gas exchange related to disruption in pulmonary perfusion

Correct answer - D Aminocaproic acid (Ami car) is an antithrombolytic drug used to prevent lysis of a clot after cerebral bleeding in an attempt to prevent rebleeding that may take place 7 to 10 days later. The drug may predispose a patient to greater risk of a thromboembolism or pulmonary embolism.

53. During the first hours after admission, Mr. D. develops spinal shock. Physical examination would then detect: A. Spasticity B. Hypertension c. Tachycardia D. Areflexia

Correct answer - D Areflexia (a loss of reflexes, sensation, and movement below the level of the lesion, lasting from minutes to weeks) occurs in acute spinal shock, which results from trauma to the spinal cord. Associated symptoms include flaccid paralysis, hypotension, and bradycardia. Paralysis becomes spastic when the patient is no longer in spinal shock. Hypotension results from loss of vascular tone below the lesion, leading to venous pooling of blood, and is usually orthostatic. Bradycardia results from loss of sympathetic activity with a relative increase in parasympathetic activity.

93. Ascending muscle weakness in the legs would suggest: A. Peripheral neuropathy B. Parkinson's disease C. Myasthenia gravis D. Guillain-Barre syndrome

Correct answer - D Ascending muscle weakness in the legs suggests Guillain-Barr syndrome. Abnormal sensations may also be felt. Peripheral neuropathy would be suggested by bilateral sensory loss in distal extremities. Tremors, rigidity, and slow movement characterize Parkinson's disease. Muscle weakness, especially of the face and respiratory musculature, suggests myasthenia gravis.

50. Which finding indicates the development of ineffective airway clearance in this patient? A. pH of 7.28, PCO2 of 36 mm Hg, HCO3 of 18 mEq, and PO2 of 86 mm Hg B. Inspiratory force of - 20 cm C. Measured tidal volume of 500 ml D. Bronchial breath sounds over the lung lobes

Correct answer - D Bronchial breath sounds over the patient's lung lobes indicate developing pneumonia, most likely caused by immobility, an ineffective cough, and a decreased vital capacity. The arterial blood gas (ABG) results indicate metabolic acidosis. An inspiratory force of- 20 cm and a tidal volume of 500 ml are normal values.

98. Electromyography is performed on Mr. M. This may be useful in diagnosing: A. Upper motor neuron lesions B. Parkinson's disease C. Seizure disorder D. Lower motor neuron disease

Correct answer - D Electromyography may aid in diagnosing lower motor neuron lesions and diseases of the muscle and myoneural junction, such as myasthenia gravis, amyotrophic lateral sclerosis, and muscular dystrophy. Electromyography records electrical activity along the muscle, which reflects its nervous innervation from the lower motor muscle, which reflects its nervous innervation from the lower motor neuron. An electromyogram may be abnormal if spinal cord compression results from a herniated disk or spinal cord tumor, but these are best diagnosed by a myelogram - a radiographic study of the spinal cord after the injection of dye.

4. The ICU nurse should prepare Mr. R. for which treatment? A. Direct intracranial pressure (ICP) monitoring B. Pharmacologic management C. Lumbar puncture D. Surgical evacuation of clot

Correct answer - D Epidural hematomas are treated by surgically evacuating the hematoma and ligating the damaged vessel. Early diagnosis and immediate surgical treatment improve the patient's prognosis.

99. Which statement describes lower motor neuron disease? A. Deep tendon reflexes are present B. It is associated with spastic paralysis c. It is a neuron disease originating in the spinal cord and ending in the brain D. It causes degenerative skin and nail changes

Correct answer - D Lower motor neuron diseases are characterized by degenerative changes of the skin and nails along the lesion and by flaccid paralysis and absent reflexes. The lower motor neuron originates in the muscle and ends in the spinal cord .

18. Nursing interventions during a generalized seizure include: A. Securing physical restraints B. Maintaining the patient in a supine position C. Inserting an artificial airway D. Observing seizure activity

Correct answer - D Nursing interventions during a generalized seizure include observing seizure activity. Noting length of seizure, time of day, presence of an aura or cry, characteristics of seizure activity, incontinence, and postictal activity may assist the physician in diagnosing the seizure and its possible cause. Assessing the pulse may help rule out a primary dysrhythmia as the seizure's cause. Physical restraint may cause an injury, such as a fracture, to the patient. The patient's head should be turned to the side to prevent aspiration of secretions. Once seizure activity has begun, the nurse should not attempt to insert an artificial airway; it may injure the patient's teeth if they are clenched, or the nurse's fingers may be bitten.

74. Assessing extraocular movements determines the function of all the following cranial nerves except the: A. Oculomotor nerve B. Trochlear nerve C. Trigeminal nerve D. Abducens nerve

Correct answer- C The fifth, or trigeminal, nerve is a sensory and motor nerve controlling sensation of the fact and innervation of the jaw muscles - not extraocular eye movements. The third, fourth, and sixth cranial nerves, known as the oculomotor system, are the oculomotor, trochlear, and abducens nerves, respectively - all motor nerves.

120. Postoperative care of Mr. S. includes: A. Maintaining high Fowler:s position B. Promoting a high-fiber diet the day after surgery C. Repositioning on alternate sides every ours D. Assessing for subdural hematoma

Correct answer - D Rapid reduction of ventricular size postoperatively may pull the dura away from the cerebrum, causing a subdural hematoma; the nurse must watch for signs of this. A headache may also follow rapid reduction in ventricular size, especially if the patient is in the upright position. The patient should be kept flat postoperatively, with the head of the bed slowly raised over a period of time, and should be kept off the operative side to avoid impeding functioning of the shunt. Usually the patient is given nothing by mouth, then started on clear liquids, to prevent complications if a paralytic ileus results.

29. Mr. J. is checked for stereognosis, which is an assessment of: A. Vision and depth perception B. Hearing C. Muscle strength D. Tactile discrimination

Correct answer - D Stereognosis is an assessment of tactile discrimination. With the eyes closed, the patient is asked to identify an object by touch. This assesses intact sensory pathways and a functioning parietal lobe. Inability to identify the object is called astereognosis.

65. Mrs. G. also begins to exhibit altered respiratory patterns from depression of the respiratory center, and is placed on a ventilator. The respiratory center in the brain is located in the: A. Cortex B. Hypothalamus C. Cerebellum D. Medulla

Correct answer - D The brain's respiratory center is in the medulla, the brain portion extending to the beginning of the spinal cord. The respiratory center has three major areas: the medullary rhythmicity, apneustic, and pneumotaxic centers. The medullary rhythmicity, or respiratory, center controls the basic rhythmicity of respiration and is affected by impulses from the spinal cord, cerebrum, pneumotaxic center, and apneustic center. The apneustic center influences depth of respirations; the pneumotaxic center influences their rate.

95. The nurse assesses for motor impairment in Mr. M. 's arms. The most reliable technique for testing arm motor strength is to: A. Observe for spontaneous movement B. Test the bicep and tricep reflexes C. Have the patient close his eyes; then ask him to identify whether you've moved his finger up or down D. Have the patient close his eyes and raise his arms straight in front or him

Correct answer - D The most reliable test of arm motor strength is to have the patient close his eyes and raise his arms straight in front of him, palms up. The nurse should watch how well this position is maintained. Observing for spontaneous movement does not assess strength. Testing reflexes assesses the intactness of the reflex arcs. Asking the patient to close his eyes and identify if you've moved his finger up or down assesses proprioceptive function.

92. High-speed impulse transmission in myelinated fibers occurs because of the: A. Nissl bodies B. Myelin sheath C. Schwann' s cells D. Nodes of Ranvier

Correct answer - D The nodes of Ranvier enable high-speed impulse transmission in myelinated fibers. The myelin sheath results from the presence of Schwann's cells or oligodendroglia; the interruption of this insulation is called a node of Ranvier. This node is highly responsive to impulse reception, and the impulse swiftly jumps from node to node, a condition known as saltatory conduction. It is actually the myelin that causes the fast conduction, with the impulse slowing at the node. Saltatory conduction prevents fatigue of the myelinated fiber, since only the node is depolarized.

55. Which statement describes the autonomic nervous system? A. The vagus nerve is the only cranial nerve controlled by the parasympathetic nervous system B. Sympathetic fibers exit the spinal cord from the cranial and sacral areas C. Postganglionic, adrenergic, and sympathetic neurons release the neurotransmitter acetylcholine D. The parasympathetic nervous system has long, preganglionic fibers that reach the innervated organ

Correct answer - D The parasympathetic nervous system has long, preganglionic fibers that reach the innervated organ. These exit from the spinal cord's cranial and sacral areas. The short postganglionic fibers of the parasympathetic nervous system, called cholinergic fibers, secrete acetycholine. The oculomotor, facial, glossopharyngeal, and vagus nerves have parasympathetic activity. Sympathetic fibers exit from the thoracolumbar areas of the spinal cord and consist of short preganglionic fibers and long postganglionic fibers. The latter, called adrenergic fibers, secrete noradrenalin.

60. In a neurologic assessment, the nurse should expect which patient to have a decreased or absent corneal reflex? A. The patient who also has normally unequal pupils B. The patient who has had recent eye surgery C. The patient with trigeminal neuralgia D. The patient who wears contact lenses

Correct answer - D The patient wearing contact lenses typically has a decreased or absent corneal reflex. This reflex helps assess the trigeminal nerve's sensory function and the facial nerve's motor function of blinking. The reflex is tested by brushing the cornea with cotton, which normally results in blinking. However, people with contact lenses accommodate to having something in their eye and respond weakly, if at all, to the corneal reflex. Otherwise, absence of this reflex indicates brain stem damage.

54. Which is true regarding autonomic dysreflexia in the spinal cordinjured patient? A. This syndrome typically occurs in patients with lumbar lesiom B. It is caused by stimulation above the level of the lesion C. It shows initial hypotension caused by vagal stimulation D. Treatment includes atropine sulfate administration

Correct answer - D Treatment of autonomic dysreflexia in the spinal cord-injured patient includes administration of atropine sulfate. Characterized by exaggerated autonomic reaction, this syndrome occurs in patients with cervical or high thoracic lesions and in response to stimuli below the level of the lesion, such as a distended bowel or bladder or an erection. The initial response is sympathetic stimulation, causing flushed skin, headache, and severe hypertension. Then, as baroreceptors are stimulated by the hypertension, parasympathetic discharge causes bradycardia. Usually, removing the stimulus may reverse the dysreflexia. If not, atropine may be administered, because it is a sympathetic, po"(ganglionic blocking agent and a vagolytic agent. It will block sympathetic impulses to the arterioles, reversing the hypertension, and will inhibit vagal action, raising the heart rate. Antihypertensives may also be used.

27. Venous blood leaves the brain through the: A. Foramen of Monro B. Aqueduct of Sylvius C. Spinal cord D. Superior sagittal sinus

Correct answer - D Venous blood leaves the brain through the superior sagittal sinus in the dura mater. The dura mater consists of an outer layer adhered to the cranial bone and an inner layer adhered to the brain. Sinuses are formed between these two layers, which drain venous blood from the brain. The blood then enters the internal jugular vein to return to the superior vena cava.

51. In spinal cord injury, early hypoventilation is best manifested by: A. Poor respiratory exchange B. Development of cyanosis C. Shortness of breath while talking D. Arterial blood gas (ABG) values

Correct answer -D In spinal cord injury, early hypoventilation is best manifested by ABG values. Poor values indicate inadequate oxygenation and ventilation. Cyanosis, a late sign of hypoventilation, is not an accurate indicator because anemic patients may never develop this sign. Cyanosis is also difficult to assess in dark-skinned persons. Poor respiratory exchange and shortness of breath while talking are symptoms related to the level of spinal cord injury and may not differentiate proper ventilation from hypoventilation.

62. Which hormone is secreted from the posterior pituitary gland? A. Antidiuretic hormone B. Follicle-stimulating hormone C. Thyroid-stimulating hormone D. Adrenocorticotropic hormone

Correct answer A Antidiuretic hormone (ADH) is secreted from and stored in the posterior pituitary gland, or neurophypophysis, which also secretes oxytocin. Its secretion is controlled by the hypothalamus. The anterior pituitary gland, or adenohypophysis, secretes growth hormone, prolactin, adrenocorticotropic hormone, thyroid-stimulating hormone, follicle-stimulating hormone, luteinizing hormone, and melanin stimulating hormone.

8. Intracranial pressure is: A. The difference between systolic and diastolic blood pressures B. Increased in hypoxic states C. Normally between 50 and 100 mm Hg D. Decreased while the patient is in the supine position

Correct answer B ICP, the difference between mean arterial pressure (MAP) and cerebral perfusion pressure (CPP), increases in hypoxic states. The cerebral blood vessels dilate when the arterial P02 drops below 50 mm Hg and when carbon dioxide is retained. A normal CPP is betwteen 50 and 130 mm Hg, while a normal ICP is between 0 and 15 mm Hg ICP is decreased with the head elevated 10 to 20 degrees, so CSF drains more easily.

109. The nurse should expect which postictal problem? A. Right side paralysis B. Loss of consciousness C. Incontinence D. Left side seizure activity

Correct answer- A A person with partial motor seizures develops paralysis of the affected side postictally. This transient paralysis, called Todd's paralysis, does not always occur after a partial motor seizure. Unconsciousness and incontinence are associated with generalized motor seizures.

101. Which of the following is the most important information for the physician to obtain before surgery? A. The dominant hemisphere B. The integrity of the corpus callosum C. The function of the upper motor neuron D. The function of the lower motor neuron

Correct answer- A Before surgery, the physician should determine which hemisphere is dominant. Because the speech centers are in the dominant hemisphere's frontal and parietal areas, speech loss may occur if the surgical site is the dominant hemisphere. The physician can detect which hemisphere is dominant by injecting a small amount of a barbiturate (usually amobarbital sodium) into one internal carotid artery. If temporary aphasia results, that side is the dominant speech center.

71. Mr. H. develops a left field visual loss, indicating damage to the: A. Optic nerve B. Oculomotor nerve C. Trigeminal nerve D. Acoustic nerve

Correct answer- A Left homonymous hemianopia indicates damage to the optic, or second, cranial nerve, specifically to the right optic tract. The optic nerve, which controls vision, originates from the retina of each eye; as it courses near the pituitary gland, half of the fibers from the nerve cross at the optic chiasm going to the opposite side of the brain, while the other half continue on the same side of the brain. The tracts then continue to the occipital lobe, where interpretation of vision occurs. Damage to the right optic tract between the optic chiasm and the occipital lobe causes loss ofleft-sided vision in each eye as the optic tracts reflect vision coming in from the opposite field.

110. Which statement describes the pathology of seizures? A. The abnormal excessive firing of brain cells causes the clinical signs and symptoms of a seizure B. The entire brain is involved in a seizure C. The metabolism of the involved cells is greatly decreased during a seizure D. The abnormal firing of the neurons, once initiated, is perpetuated indefinitely until therapy is instituted

Correct answer- A The abnormal excessive firing of cells in a portion of all of the brain causes the clinical signs and symptoms of a seizure. The metabolism of the involved cells is greatly increased during seizure activity. The abnormal firing of the neurons can terminate as abruptly as it begins.

119. A ventriculoperitoneal shunt is implanted in Mr. S. Which is a common postoperative nursmg diagnosis? A. Decreased cardiac output related to altered cardiac conduction. B. Constipation related to lack of per~stalsis . t f C. Fluid volume deficit related to active gastrointestinal blood loss. D. Fluid volume excess related to hormonal tmbalances

Correct answer- B Paralytic ileus may occur postoperatively from manipulation of the bowel when inserting the shunt into the peritoneum. Postoperatively, the patient is given nothing by mouth for a few days, then is started on clear liquids, and bowel status is frequently assessed.

89. Care of Ms. 0. includes: A. Withholding anticholinesterase agents if muscle weakness occurs B. Administering quinine for leg cramps C. Assessing forced vital capacity before and after each dose of an anticholinesterase agent D. Scheduling activities for the afternoon to avoid muscle fatigue

Correct answer- C Care in myastenia gravis includes assessing forced vital capacity before and after each dose of an anticholinesterase. Because this disease is characterized by weakness of skeletal muscles, respiratory muscle strength is a reliable indication of proper medication dosage. Anticholinesterase medication should be given promptly and should not be withheld because of muscle weakness. Muscle weakness from an overdose of anticholinesterase medication can be reversed by administering atropine. The patient should not be given medications that may precipitate severe muscle weakness, such as quinidine, quinine (and tonic water, which contains quinine), procainamide, aminoglycosides, and curare. Activities should be performed in the morning, with rest periods in the afternoon to avoid fatigue.

118. Which type of hydrocephalus does not warrant a shunt implant? A. Communicating B. Noncommunicating C. Normal-pressure . D. Excessive CSF productiOn

Correct answer- C Normal-pressure hydrocephalus does not increase ICP. This results from dilation of the ventricles from an unknown cause.

107. If damage occurred to the sixth cranial nerve during surgery, the nurse would observe which condition? A. Absent gag reflex B. Fixed and dilated pupils C. Nystagmus D. Inward deviation of the eyes

Correct answer- D Inward deviation of the eyes would indicate damage to the sixth cranial nerve, the abducens. The gag reflex is controlled by the ninth and tenth cranial nerves, the glossopharyngeal and vagus nerves, respectively. The third cranial nerve, the oculomotor, controls pupillary constriction and dilation. Interruption of cerebellar function causes nystagmus.

82. The organism that most frequently causes meningitis in young adults is the: A. Hemophilus influenza.e B. Pneumococcus C. Meningococcus D. Streptococcus

Meningococcus most commonly causes meningitis in young adults. Meningococcal meningitis, which spreads via the nasopharynx by intimate contact or droplets, is the most contagious form of the disease and causes the highest mortality. Penicillin is the drug of choice. Hemophilus influenzae is the most common cause of meningitis in children, and pneumococcus, the most common cause in adults over age 40.