Chapter 23 JARVIS

A 70 yr woman tells the nurse that every time she gets up in the morning. she gets "really dizzy"

ANS: "You need to get up slowly when you've been lying or sitting."

Which of these statements about the peripheral nervous system is correct?

ANS: The peripheral nerves carry input to the central nervous system by afferent fibers and away by efferent fibers.

When taking the history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura.

ANS: "Do you have any warning sign before your seizure starts?" Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or motor.

In 74-year-old patient the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands.

ANS: "Does the tremor change when you drink the alcohol?" Senile tremor is relieved by alcohol, although this is not a recommended treatment.

During the assessment of deep tendon reflexes, the nurse finds that a patient's responses are normal bilaterally. What number is used to indicate "normal" deep tendon reflexes when the documenting this finding. _____+

ANS: 2 Responses to assessment of deep tendon reflexes are graded on a 4-point scale. A rating of 2+ indicates normal or average response. A rating of 0 indicates no response, and a rating of 4+ indicates very brisk, hyperactive response with clonus, which is indicative of disease.

Using the Glasgow Coma Scale, which number indicates that the patient is in a coma?

ANS: 6 A fully alert, normal person has a score of 15, whereas a score of 7 or less reflects coma on the Glasgow Coma Scale.

To test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate?

ANS: Ask child to hop on one foot.

The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding?

ANS: Astereognosis Stereognosis is the person's ability to recognize objects by feeling their forms, sizes, and weights. Astereognosis is an inability to identify objects correctly, and it occurs in sensory cortex lesions. .

During the history of a 78-year-old man, he occasionally has short-term memory loss and confusion: "He can't even remember how to button his shirt."

ANS: Before testing, the nurse would assess the patient's mental status and ability to follow directions at this time.

A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance.

ANS: Cerebellum coordinates movement, maintains equilibrium, and helps maintain posture.

determining whether a person is oriented to his or her surroundings will test ?

ANS: Cerebrum The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement.

A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. Alzheimer's disease?

ANS: Difficulty performing familiar tasks, such as placing a telephone call Misplacing items, Rapid mood swings, from calm to tears, Getting lost in one's own neighborhood

a 29-year-old woman who visits the clinic complaining of "always dropping things and falling down." the woman is unable to pat both her knees.

ANS: Dysfunction of the cerebellum

In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect to see?

ANS: Hyperreflexia Hyperreflexia, diminished or absent superficial reflexes, and increased muscle tone or spasticity can be expected with upper motor neuron lesions.

A 59-year-old patient has a herniated intervertebral disk.

ANS: Hyporeflexia With a herniated intervertebral disk or lower motor neuron lesion there is loss of tone, flaccidity, atrophy,

assessment of a 22-year who has a head injury, the nurse notices the right pupil is fully dilated and nonreactive, left pupil is 4 mm and reacts to light.

ANS: Increased intracranial pressure .

a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation?

ANS: Lateral spinothalamic tract, thalamus, and sensory cortex .

The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment?

ANS: Level of consciousness, motor function, pupillary response, and vital signs .

assessment of a "healthy" 35-year-old patient, the The nurse then moves each extremity through full range of motion.

ANS: Mild, even resistance to movement

the nurse finds the following: asymmetry when the patient smiles uneven lifting of eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek.

ANS: Motor component of VII

The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect?

ANS: Peripheral neuropathy Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism). Peripheral neuropathy is worse at the feet and gradually improves as the examiner moves up the leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome.

In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise or stimulation. The mother reports that in the last week he has been sleeping all the time, and when he is awake all he does is cry. The nurse hears that the infant's cries are very high pitched and shrill. What should be the nurse's appropriate response to these findings?

ANS: Refer the infant for further testing. A high-pitched, shrill cry or cat-sounding screech occurs with central nervous system damage. Lethargy, hyporeactivity, hyperirritability, and parent's report of significant change in behavior all warrant referral. The other options are not correct responses.

While obtaining a history of a 3-month-old infant, the nurse asks about the infant's ability to suck and grasp mother's finger.

ANS: Reflexes

A 21-year-old patient has a head injury resulting from trauma. what is expected when testing the patient's deep tendon reflexes?

ANS: Reflexes will be normal. A reflex is a defense mechanism of the nervous system.

A patient has a severed spinal nerve as a result of trauma.

ANS: The adjacent spinal nerves will continue to carry sensations for the dermatome. A dermatome is a circumscribed skin area that is supplied mainly from one spinal cord segment through a particular spinal nerve.

Which of these statements concerning areas of the brain is true?

ANS: The hypothalamus controls temperature emotions and regulates sleep. The cerebellum-motor coordination, equilibrium, balance. The basal ganglia control autonomic movements of the body.

A patient with lack of oxygen, yet pain in his chest and possibly the shoulder, arms,

ANS: The sensory cortex does not have the ability to localize pain in the heart, so the pain is felt elsewhere.

During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. There is no associated rigidity with movement. Which of these statements is most accurate?

ANS: These are normal findings resulting from aging. Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson disease include rigidity, slowness, and weakness of voluntary movement. The other responses are incorrect.

32-year-old patient with head injury, the patient responds to pain by extending, adducting, and irotating his arms. palms pronate and his lower extremities extend with plantar flexion.

ANS: This is a very ominous sign and may indicate brainstem injury.

The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this?

ANS: This is most likely the result of the summation effect. Let at least 2 seconds elapse between each stimulus to avoid summation. With summation, frequent consecutive stimuli are perceived as one strong stimulus. The other responses are incorrect.

While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of arms and legs; fanning of fingers, and curling of index and thumb in a C position followed by infant bringing in arms and legs to body. What does the nurse know about this response?

ANS: This reflex should have disappeared between 1 and 4 months of age. The Moro reflex is present at birth and disappears at 1 to 4 months.

a patient who has a late-stage brain tumor. the patient's toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as:

ANS: a positive Babinski's sign, which is abnormal for adults. Dorsiflexion of the big toe and fanning of all toes is a positive Babinski's sign, also called "upgoing toes

two parts of the nervous system are the:

ANS: central and peripheral. The cns includes the brain and spinal cord. The pns 12 pairs of cranial nerves, 31 pairs of spinal nerves, and branches.

The ability that humans have to perform very skilled movements such as writing is controlled by the:

ANS: corticospinal tract. Corticospinal fibers mediate voluntary movement, particularly very skilled, discrete, purposeful movements, such as writing.

While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of:

ANS: decreased level of consciousness. A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect.

The wife of a 65-year-old man has change in personality and ability to understand. He also cries. The nurse recalls that the cerebral lobe responsible for these behaviors is the _____ lobe.

ANS: frontal The frontal lobe has areas concerned with personality, behavior, emotions, and intellectual function. The parietal lobe has areas concerned with sensation; the occipital lobe is responsible for visual reception; and the temporal lobe is concerned with hearing, taste and smell.

The nurse is testing the function of cranial nerve XI. intact?

ANS: moves the head and shoulders against resistance with equal strength. Checking the patient's ability to hear CN VIII. stick out the tongue checks the function of CN XII. Testing the eyes CN III, IV, and VI.

A mother of a 1-month-old infant asks the nurse why it takes so long for infants to learn to roll over.

ANS: myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated.

During an assessment of an 80-year-old patient, the nurse notices slightly impaired tactile sensation. All other neurologic findings are normal.

ANS: normal changes due to aging.

During an assessment of a 62-year-old man the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements.

ANS: parkinsonism.

The nurse knows that testing kinesthesia is a test of a person's:

ANS: position sense. Kinesthesia, or position sense, is passive movements of the extremities.

When the nurse asks a 68-year-old patient to stand with feet together and his eyes closed, he starts to sway and moves his feet farther apart.

ANS: positive Romberg sign. Positive Romberg sign is loss of balance that is increased by closing of the eyes. Ataxia is unsteady gait. Homans' sign is used to test the legs for deep vein thrombosis.

The area of the nervous system that is responsible for reflexes

ANS: spinal cord.

A patient is not able to perform rapid alternating movements such as patting her knees rapidly. The nurse should document this as:

ANS: the presence of dysdiadochokinesia. Slow clumsy movements and the inability to perform rapid alternating movements are condition of dysdiadochokinesia. Ataxia is uncoordinated or unsteady gait. Astereognosis is the inability to identify an object by feeling it. Kinesthesia is the person's ability to perceive passive movement of the extremities, or the loss of position sense.

During the history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this as:

ANS: vertigo. Dizziness is a lightheaded, Syncope is a sudden loss of consciousness. .

Which of these tests would the nurse use to check the motor coordination of an 11-month-old infant?

Denver II- to screen gross and fine motor coordination, the nurse should use the Denver II

During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which of these conclusions by the nurse is correct?

This may indicate disease of the cerebellum or brainstem. End-point nystagmus at an extreme lateral gaze occurs normally.