Sensory Neuro quiz
What substance is it most appropriate for the nurse to use to remove an insect from a patient's ear? 1 Water 2 Alcohol 3 Mineral oil 4 Hydrogen peroxide
Mineral oil causes the least amount of trauma and irritation to the ear canal. Water and hydrogen peroxide should not be used because the insect could swell, which would make it more difficult to remove. Alcohol may cause both irritation of the ear canal and swelling of the insect. Text Reference - p. 403 3
A patient has experienced a right brain stroke. What intervention would be most important to include in the plan of care? 1 Allow extra time for transfer and activity. 2 Assist with self-catheterization every four hours. 3 Evaluate body positioning during all transfers. 4 Provide activities that promote verbal memory skills.
Patients who have experienced a right brain stroke are more likely to have problems with spatial-perceptual orientation. One spatial-perceptual deficit is neglect, where the patient neglects all input from his or her own body part, often the left side of the body. It is important for staff members to evaluate body position during transfers to assure the left sided-extremities are in anatomical alignment to minimize injury. Patients with right-sided brain stokes generally are impulsive and move more rapidly, while left-sided brain strokes are more slow and cautious. Generally, the prognosis for normal bladder function is excellent, allowing for partial to complete bladder evacuation without any interventions such as intermittent catheterizations. Memory can be affected with strokes involving either side of the brain; verbal memory skills are most affected with left brain strokes. Text Reference - p. 1409 3
When planning for venous thromboembolism (VTE) prevention, the nurse places as priority: 1 Application of compression stockings on legs. 2 Active and passive range-of-motion (ROM) exercises. 3 Use of sequential compression devices on lower legs. 4 Administration of daily enoxaparin (Lovenox) injections.
The most effective prevention of VTEs is to keep the patient moving. VTEs develop because of immobility, loss of venous tone, and decreased muscle pumping activity in the legs. If able, the patient can perform active ROM exercises, such as foot pumps, ankle circles, and flexion and extension of legs. If unable to perform, the staff should perform scheduled passive ROM exercises. Use of compression stockings (TED hose) and sequential depression devices, when used appropriately, are effective in preventing VTEs. The use of enoxaprin is also effective at preventing VTEs, but is not without risks, such as bleeding and excessive bruising. Text Reference - p. 1405 2
To determine the integrity of the facial nerve (CN VII), the nurse will ask the patient to do which of the following? Select all that apply. 1 Clench teeth 2 Stick out tongue 3 Say "ga, ga, ga" 4 Raise eyebrows 5 Purse lips together 6 Close eyes tightly
To assess the motor function of the fa cial nerve (CN VII), assessments include asking the patient to raise eyebrows, close eyes tightly, purse the lips, perform an exaggerated smile, and frown. The nurse is looking for any asymmetry in facial movements. Clenching teeth while palpating the masseter muscles is assessing the trigeminal nerve (CN V). Extending the tongue assesses the hypoglossal nerve (CN XII). Asking the patient to say "ga, ga, ga" requires movement of the pharynx and tongue, therefore assessing cranial nerve IX, the glossopharyngeal. Text Reference - p. 1347 3,4,5
During recovery from a lumbar puncture, the patient reports a severe headache. What is the most appropriate action for the nurse to take? Correct1 Increasing the patient's fluid intake 2 Checking the patient for urine retention 3 Placing the patient in a side-lying position 4 Placing cool packs over the patient's lumbar puncture site
headache after a lumbar puncture is usually caused by leakage or loss of cerebral spinal fluid (CSF). Increased fluid intake, either IV or oral as tolerated, will help restore CSF volume. The patient should be encouraged to lie flat for 4 to 6 hours. A persistent headache may indicate a CSF leak. Checking for urine retention and placing cool packs over the puncture site are incorrect and inappropriate interventions to treat a severe headache after a lumbar puncture. Text Reference - p. 1352 1
A nurse is interviewing a patient who is seeking relief for frequent headaches. Which description is consistent with symptoms of a migraine headache? 1 Extreme tenseness in the area of the neck and shoulders. 2 Tears flow from one eye and nasal drainage occurs with the headache. 3 The pain of the headache wakes the patient from sleep. 4 The pain throbs and is synchronous with the patient's pulse.
A migraine headache is caused by a series of neurovascular events that result from some trigger stimulus. The pain usually is one-sided, throbbing in nature, and synchronous with the patient's pulse. Palpable tenseness in the neck and shoulders occurs with a tension headache. A cluster headache awakens the patient from sleep and involves tearing of one eye with nasal drainage on the same side. Text Reference - p. 1414 4
What precautions should the nurse follow when feeding a patient with a stroke on the left side? Select all that apply. 1 Place the patient in high Fowler's position. 2 Place the patient in a chair with the head flexed forward. 3 Place the patient in low Fowler's position. 4 Place the patient in Trendelenburg's position. 5 Place the patient in right lateral position.
A person in a Fowler's position is sitting straight up or leaning slightly back. Their legs may either be straight or bent. A high Fowler's position is someone who is sitting upright. This helps in feeding as well as swallowing for the patient. Sitting in a chair with the head flexed forward also serves a similar purpose. Low Fowler's, Trendelenburg's, and right lateral positions are not appropriate for feeding. Text Reference - p. 1406 1,2
Identify a causative factor associated with a sensorineural hearing loss. 1 Otosclerosis 2 Impacted cerumen 3 Perforation of the tympanic membrane 4 Ototoxicity from chemotherapeutic medications
A sensorineural hearing loss involves damage to the neural component of hearing. Within the inner ear there are sensory hair cells in the cochlea that pick up impulses and initiate nerve impulse to the brain via the acoustic branch of the eighth cranial nerve. Medications, including some chemotherapy, can damage this nerve pathway of hearing. Otosclerosis is a hereditary condition causing a conductive hearing loss because of bony growth that limits the stapes from vibrating in response to sound. Impacted cerumen (earwax) causes a conductive hearing loss because the sound vibrations are blocked by excessive earwax in the ear canal. A perforated tympanic membrane (ruptured eardrum) causes a conductive hearing loss because the tympanic membrane is no longer intact to adequately conduct sound vibrations. Text Reference - p. 407 4
A patient complains of a decrease in the sense of smell. What could be the possible reasons for this symptom? Select all that apply. Correct 1 Heavy smoking Correct 2 Basilar skull fracture 3 Damage to vagus nerve 4 Damage to the trochlear nerve 5 Damage to glossopharyngeal nerve
Chemicals in cigarette smoke may damage the olfactory receptor cells, thus affecting the ability to smell. The basilar skull fracture may damage the olfactory fibers as they pass through the delicate cribriform plate of the skull, thus affecting the ability to smell. The vagus nerve has sensory functions on the viscera of the thorax and abdomen. The trochlear nerve is associated with eye movement. The glossopharyngeal nerve is associated with taste sensation and motor activity of the superior pharyngeal muscles. Text Reference - p. 1346 1,2
A patient presenting with stroke symptoms is being considered for fibrinolytic therapy. What assessment data would be important to communicate promptly to the prescribing health care provider? 1 History of transient ischemic attack (TIA) six months ago. 2 Presence of indwelling urinary catheter. 3 Removal of soft tissue tumor from back three weeks ago. 4 Colonoscopy for evaluation of blood in the stools one week ago.
Contraindications for fibrinolytic therapy include recent history of gastrointestinal bleeding, stroke, or head trauma within three months or major surgery within 14 days. It would be most important for the nurse to inform the prescriber of the history of blood in the stools. Patients who have experienced a TIA are at greater risk of having a stroke. A history of TIA or presence of an indwelling urinary catheter are not contraindications for fibrinolytic therapy. Removal of a soft tissue tumor from the back does not fall in the category of major surgery, and this patient's surgery is beyond the 14 day window. Text Reference - p. 1398 4
A patient reports, "While I was walking I got something in my eye." What nursing intervention is most appropriate for a patient with a suspected foreign object in the eye? 1 Beginning irrigation with sterile normal saline solution 2 Attempting to remove the object without causing further damage to the eye 3 Refraining from doing anything until the patient can be seen by an ophthalmologist 4 Loosely covering the eye with a sterile patch and referring the patient to emergency care
Covering the eye loosely with a sterile patch with referral for emergency care is the safest option for this patient. Eye irrigation and attempting to remove the object are not appropriate in this healthcare setting. The nurse should never attempt to remove a foreign object from the eye, because this could cause further damage. The patient should be seen by the an eye specialist, but covering the eye with an eye patch will prevent further trauma and irritation. Text Reference - p. 390 4
A nurse is caring for a patient who becomes agitated in the evening. What nursing interventions are most helpful? Select all that apply. 1 Creating a calm environment 2 Allowing the patient to sleep for long hours 3 Isolating the patient to minimize stimuli 4 Limiting caffeine intake 5 Consulting with the health care provider
Creating a calm environment reduces agitation in the patient; restraining or threatening the patient can worsen the problem. Caffeine is a stimulant, so limiting caffeine intake would help in reducing agitation. Healthcare providers should be consulted if antianxiety drugs or sedatives need to be prescribed. Do not allow the patient to sleep for long hours at night, and limit daytime naps. Maximize the exposure to daylight rather than isolating the patient. Text Reference - p. 1454 1,4,5
The nurse is discussing glaucoma prevention with a 52-year-old African-American patient. Which statement by the patient reflects a correct understanding of glaucoma prevention? 1 "I will visit my eye doctor every one to two years." 2 "I will wear protective sunglasses while outside." 3 "I will take lutein and vitamin E supplements for eye health." 4 "There is nothing that can be done to prevent vision loss from glaucoma."
Loss of vision as a result of glaucoma is a preventable problem. Teach the patient and the caregiver about the risk of glaucoma and that it increases with age. Stress the importance of early detection and treatment in preventing visual impairment. A comprehensive ophthalmic examination is important in identifying persons with glaucoma or those at risk of developing glaucoma. The current recommendation is for an ophthalmologic examination every two to four years for persons between ages 40 and 64 years, and every one to two years for persons age 65 years or older. African Americans in every age category should have examinations more often because of the increased incidence and more aggressive course of glaucoma in these individuals. Wearing protective sunglasses while outside may help to reduce the development of cataracts, not glaucoma. Lutein and vitamin supplements may be helpful for preventing macular degeneration, not glaucoma. Text Reference - p. 401 1
A nurse is providing information to a group of nursing students, explaining the difference between a migraine headache and a tension-type headache. What should the nurse include as diagnostic criteria for a migraine headache? 1 Unilateral pain 2 Non-throbbing pain 3 Movement does not affect its severity 4 Photophobia or phonophobia but not both
Migraine headaches have at least 2 of the following characteristics: unilateral; throbbing; aggravated by movement; moderate to severe intensity. Migraine headaches also have at least one of the following charactistics: nausea/vomiting; photophobia and phonophobia. Tension-type headaches have at least 2 of the following characteristics: bilateral; non-throbbing; movement does not affect its severity; mild to moderate intensity. Tension-type headaches also have at least one of the following characteristics: no nausea/vomiting; photophobia or phonophobia but not both. 1
A patient underwent aneurysm clipping six hours ago for subarachnoid hemorrhage and is being treated with nimodipine. While examining the patient, the nurse finds that the pulse of the patient is 50 beats per minute (bpm) and the blood pressure is 90/60 mm Hg. What should the nurse do? 1 Encourage intake of fluids orally. 2 Monitor blood pressure every half hour. 3 Start intravenous fluids to increase blood volume. Correct4 Hold the medication and contact the primary health care provider
Nimodipine is a calcium channel blocker that is given to patients with subarachnoid hemorrhage to decrease the effects of vasospasm and to minimize cerebral damage. Nimodipine lowers the blood pressure, and therefore before administration, it is important to assess the blood pressure and apical pulse. If the pulse and blood pressure drop (pulse is less than 60 beats per minute and systolic blood pressure is less than 90 mm Hg), the medication should be stopped and the primary healthcare provider should be contacted immediately. The nurse should not start IV fluids without contacting the health care provider first. The blood pressure may be monitored more frequently if they are in intensive care or unstable. The patient may be NPO or unable to have oral fluids at this point. Text Reference - p. 1395 4
A nurse taps the triceps tendon just above the olecranon process in a patient with the elbow flexed and the forearm resting across the patient's chest. Which reactions indicate a normal response? Select all that apply. 1 Continued rhythmic contraction of the muscle 2 Flexion of the arm Correct 3 Extension of the arm Correct 4 Contraction of triceps muscle 5 Relaxation of triceps muscle
The triceps reflex is elicited by striking the triceps tendon above the elbow while the patient's arm is flexed. The normal response is extension of the arm or visible contraction of the triceps. Clonus is an abnormal response characterized by a continued rhythmic contraction of the muscle with continuous application of the stimulus. Flexion of the arm and relaxation of the triceps muscle when eliciting the triceps reflex are abnormal responses and indicate a dysfunctional neurological system. 3,4
What suggestion should the nurse give to the family members of a patient with Parkinson's disease to promote self-care and independence of the patient? Select all that apply. 1 Use slip-on shoes. 2 Use rugs on the floor. 3 Use an elevated toilet seat. 4 Use buttons and hooks on clothes. 5 Elevate the legs on an ottoman when sitting.
To promote self-care and independence of the patient, certain changes in the home environment can be made. Slip-on shoes should be used, because they can be easily put on or taken off by the patient. Elevated toilet seats help with getting on and off the toilet easily. Legs can be elevated on an ottoman to prevent ankle edema. Rugs should be removed, because they can cause the patient to fall. Hooks and buttons as clothing fasteners may be difficult for the patient to use; instead, hook-and-loop (Velcro) fasteners or zippers should be used. Text Reference - p. 1437 1,3,5
The nurse is caring for a patient with Alzheimer's disease. Which pathophysiologic proteins are associated with Alzheimer's disease? Select all that apply. 1 Pick bodies 2 α-Synuclein 3 Prion protein 4 β-Amyloid 5 Tau protein
β-Amyloid and tau proteins are associated with Alzheimer's disease. Development of plaques in the brain tissue is a part of aging; however, in patients with Alzheimer's disease, these plaques are seen in specific parts of the brain. These plaques are made up of clusters of insoluble deposits of a protein called β-amyloid, other proteins, remnants of neurons, nonnerve cells such as microglia, and other cells such as astrocytes. Tau proteins, through the microtubules, provide support to the intracellular structures in the central nervous system. In Alzheimer's disease, the tau protein is altered, which in turn causes the microtubules to twist together in a helical fashion. This twisting of microtubules results in formation of neurofibrillary tangles, a characteristic finding in the neurons of persons with Alzheimer's disease. Prion proteins are related to Creutzfeldt-Jakob disease, which is a rare and fatal brain disorder. Pick bodies are associated with frontotemporal lobar degeneration, which is a clinical syndrome associated with shrinking of the frontal and temporal anterior lobes of the brain. α-Synuclein is a protein associated with dementia with Lewy bodies in the brainstem and cortex. Lewy bodies are abnormal deposits of α-synuclein. Text Reference - p. 1446 4,5