Ch. 25 neuro

A client is in the emergency room with what could be a lumbar injury. Which deep tendon reflex would be most appropriate to test?

patellar

The nurse is assessing an older adult client when the client tells the nurse that she has experienced transient blind spots for the last few days. The nurse should refer the client to a physician for possible

stroke

A 41-year-old real estate agent comes to the office saying that he feels like his face is paralyzed on the left. He states that last week he felt his left eyelid was drowsy; as the day progressed he could not close his eyelid all the way. Later he felt like his smile became affected also. He denies any recent injuries but had an upper respiratory viral infection last month. Past medical history is unremarkable. He is divorced with one child. He smokes one pack of cigarettes a day, occasionally drinks alcohol, and denies any illegal drug use. His mother has high blood pressure and his father has sarcoidosis. On examination the nurse asks the client to close his eyes. He cannot close his left eye. The nurse asks him to open his eyes and raise his eyebrows. His right forehead furrows but his left remains flat. The nurse then asks the client to give a big smile. The right corner of his mouth raises but the left side of his mouth remains the same. What type of facial paralysis does he have?

Peripheral CN VII (facial) paralysis

Which tests are appropriate for a nurse to perform to test cranial nerve VIII (vestibulocochlear)?

Whisper, Rinne, and Weber tests Cranial nerve VIII is the acoustic/vestibulocochlear nerve, which is associated with the client's ability to hear. The nurse should perform the whisper test and, using the tuning fork, the Rinne and Weber tests. The gag reflex, rise of the uvula, and ability to swallow are tests to assess cranial nerves IX (glossopharyngeal) and X (vagus). Asking the client to smile, frown, show teeth, and puff out the cheeks assesses the function of cranial nerve VII (facial). Clenching the teeth, identifying light touch, and discriminating between sharp and dull stimuli are assessments of cranial nerve V (trigeminal).

A client visits the clinic and tells the nurse that he has not been feeling very well. The nurse observes that the client's speech is slow, the client has a disheveled appearance, and he maintains poor eye contact with the nurse. The nurse should further assess the client for

depression

A nurse cares for a client diagnosed with cranial nerve III (oculomotor) disorder. What should the nurse expect to find in the client?

drooping of eyelids The client with disorder of cranial nerve III will have drooping of the eyelids. Inability to close eyes occurs due to damage of cranial nerve VII. Loss of visual field and swelling of the optic nerve occur due to damage of cranial nerve II.

Upon reviewing the client's medical record, the nurse finds the client has left ptosis. The nurse would assess the client for what?

drooping of left eye

When testing the biceps reflex, what type of response should the nurse expect if normal?

elbow flexes and muscle contracts

A nurse is planning care for a client who has been diagnosed with restless leg syndrome. Which intervention is the most effective for temporary relief of the symptoms?

exercising the legs

The Glasgow Coma Scale measures the level of consciousness in clients who are at high risk for rapid deterioration of the nervous system. A score of 13 indicates

some impairment The points associated with the Glasgow Coma Scale are determined to assess levels of consciousness and coma. Points are allotted for each of the 3 areas: eye opening, verbal response and motor responses. A score of 13 indicates some impairment.

A nurse is preparing to offer a community education session on anxiety. Which part of the nervous system should the nurse include in the discussion?

sympathetic nervous system The sympathetic nervous system mobilizes organs and their functions during times of stress and arousal such as with the experience of anxiety. The peripheral nervous system supplies nerve stimulation to the heart, visceral organs, skin, and the extremities. The autonomic nervous system connects to internal organs and generates autonomic reflex responses. The somatic nervous system regulates muscle movements and response to sensations of touch and pain.

The hypothalamus is responsible for regulating

circadian rhythm

The cerebrum is divided into right and left hemispheres, which are joined together by the

corpus callosum

The nurse is assessing the neurologic system of an adult client. To test the client's use of memory to learn new information, the nurse should ask the client

"Can you repeat brown, chair, textbook, tomato?"

when evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as being at highest risk?

68-year-old African American male with hypertension

A client reports the feeling of being unsteady when walking. What is an appropriate action by the nurse to assess for a problem with gait and balance?

Ask the client to walk in a heel-to-toe fashion and watch for an unsteady gait

The nurse suspects that a client is experiencing meningitis. Which assessment finding caused the nurse to make this clinical determination?

Pain and hip flexion when the neck is flexed

A client is admitted to the health care facility with new onset of right-sided paralysis, slurred speech, and lethargy. A nurse obtains in the history that the client has uncontrolled hypertension and smokes 2 packs of cigarettes a day. Which nursing diagnosis is priority for the client upon admission?

risk for aspiration

The nurse is caring for a client during the immediate postoperative period after abdominal surgery. While performing a "neuro check" the nurse should assess the client's

sensation in the extremities.

What task should a nurse ask a client to perform to assess the function of cranial nerve XI accessory?

shrug shoulders against resistance

Where do the cell bodies of the lower motor neurons lie?

spinal cord

Sensations of temperature, pain, and crude and light touch are carried by way of the

spinothalamic tract

The diencephalon of the brain consists of the

thalamus and hypothalamus

The nurse is providing teaching to a client with type 1 diabetes. When providing information about reducing the risk of diabetic neuropathy, the nurse should be sure to include which point?

"Effective blood glucose regulation can prevent this problem."

How many pairs of cranial nerves exit from the brain?

12 The 12 paired cranial nerves exit from the brain, not the spinal cord. Some cranial nerves have only a sensory component, some have only a motor component, and others have both.

The nurse plans to test which cranial nerve when testing an elderly client's hearing status?

CN VIII vestibulocochlear

What should the nurse assess to test the function of the frontal lobe?

Communication

Which of the following would the nurse expect to assess if a client has a lesion of the sympathetic nervous system?

Constricted pupil unresponsive to light

A client cannot differentiate between sharp and dull pain sensations when a nurse tests with a safety pin. What is an appropriate action by the nurse?

Determine the ability to differentiate hot and cold temperatures

While performing a neurological assessment on a 56-year-old male, the nurse identifies the client may be experiencing a stroke. What symptoms would the nurse identified? Select all that apply.

Difficulty following instructions, slurred speech, impaired vision

When assessing a client's coordination by asking the client to touch the nose with the finger, what should a nurse keep in mind about a client's movements?

Dominant side will be more coordinated than nondominant side

Nursing students are doing a class presentation on stroke. What is the term they would use for deficits in speech articulation?

Dysarthria

Characteristics of the 12 cranial nerves include all of the following except that:

Each has motor and sensory functions.

Which part of the brain controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions and maintains overall autonomic control?

Hypothalamus

When examining the eye, the nurse notices difficulty with downward motion. The nurse understands that which cranial nerve is involved?

IV trochlear (medial)

The nurse assesses the motor system as part of the full neurological examination. In order to effectively assess this system, which of the following instructions should be given to the client?

Instruct the client to flex and extend the right elbow Instructing the client to flex and extend the right elbow is assessing strength, which is a part of the motor system assessment. Instructing the client to state the current date and place is part of the mental status assessment. Instructing the client to smile and close the eyes is part of the cranial nerve assessment.

When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence?

Mental status, cranial nerves, motor/cerebellar, sensory, reflexe

The nurse is assessing the neurologic system of an adult client. To test the client's motor function of the facial nerve, the nurse should

Purse the lips

A client is clenching the jaw closed to avoid taking a prescribed oral medication. The nurse can use this observation to confirm the client is demonstrating motor function of which cranial nerve?

V trigeminal

The nurse notes that a client does not blink the left eye when the cornea is lightly touched with a cotton wisp. On which cranial nerve should the nurse focus additional assessment?

V trigeminal Testing for the corneal reflex assesses a branch of cranial nerve V, the trigeminal nerve. Cranial nerve II is the optic nerve. Cranial nerve III is the oculomotor nerve. Cranial nerve IV is the trochlear nerve. Cranial nerves II, III, and IV do not control the corneal reflex.

A nurse is assessing a client for abnormalities of gait due to a concern that the client is at increased risk for a fall. Which instruction should the nurse give the client first?

Walk across the room & back

The nurse has completed a Glasgow Coma Scale assessment and assigns the client a score of three. Which is the best way for the nurse to assess pain in this client?

assess for nonverbal signs

When testing sensory function of the trigeminal nerve (CN V), which of the following sensations would the nurse assess?

pain and light touch

The client presents at the clinic with a complaint of weakness that is made worse with repeated effort and improves with rest. The client's complaint is consistent with what health problem?

myasthenia gravis Weakness made worse with repeated effort and improved with rest suggests myasthenia gravis.

During the Romberg test, a client is unable to stand with his feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would identify this as which of the following?

cerebellar ataxia A wide-based, staggering, unsteady gait and positive Romberg test (client unable to stand with feet together) suggest cerebellar ataxia. Spastic hemiparesis is characterized by a flexed arm held close to the body while the client drags the toes of the leg or circles it stiffly outward and forward. A Parkinsonian gait is a shuffling gait. A scissors gait is a short stiff gait with the thighs overlapping each other with each step.

The nurse is assessing the client's coordination and finds that her movements are clumsy, unsteady, and inappropriately varying in their speed, force, and direction. The nurse notes that client has dysmetria. What would the nurse know this client has?

cerebellar disease

The portion of the brain that rims the surfaces of the cerebral hemispheres forming the cerebral cortex is the

Grey matter

A nurse assesses a client for pupillary response of the eyes and finds a unilateral dilated pupil that is unresponsive to light or accommodation. The nurse recognizes that which cranial nerve is responsible for the damage of pupillary response?

III oculomotor

A client who was injured by a fall at a construction site has been admitted to the hospital. He has suffered nerve damage such that his gag reflex is no longer intact, requiring him to receive intravenous total parenteral nutrition. Which nerve should the nurse suspect to be involved in this client's injury? the cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the

IX glossopharyngeal

When the nurse is assessing the motor function of cranial nerve VII as part of the neurological examination, what should the nurse instruct the client to do?

Smile