chapter 25: Assessing Neurologic System
What instruction should a nurse give a client when having trouble eliciting a response from testing the patellar deep tendon reflex? a) "Place your hands together, lock your fingers, and squeeze." b) "Tighten the thigh muscles of the opposite leg." c) "Clench your teeth and breathe slowly and deeply." d) "Close your eyes and imagine you are somewhere else."
a) "Place your hands together, lock your fingers, and squeeze." If deep tendon reflexes are diminished or absent, a reinforcement technique may be used to enhance the client's response. When testing the leg reflexes, have the client interlock the hands and squeeze. Closing the eyes and tightening the thigh muscles of the opposite leg will not aid in eliciting a reflex response. Clenching the teeth is a reinforcement technique that is helpful to elicit a response when assessing the arm reflexes.
A nurse is testing a client's corneal reflex but notices that the reflex appears to be reduced. The client is otherwise alert and oriented, with no signs of neurologic degeneration. What is an appropriate action by the nurse? a) Ask the client about the presence of contact lenses b) Allow the client to blink a few times then repeat test c) Rinse the eye and then attempt the test again d) Touch the cornea with a small piece of cotton
a) Ask the client about the presence of contact lenses The corneal reflex test is done to assess the sensory portion of cranial nerve V (trigeminal). If the client has an intact nervous system, the nurse should ask about the presence of contact lenses because they can cause the reflex to be absent or reduced. Touching the cornea with a small piece of cotton is how the test is performed. Blinking or rinsing the eyes is not an appropriate action.
A client has a disorder of the hypothalamus. The nurse recognizes that this structure is found in which area of the brain? a) Diencephalon b) Brain stem c) Cerebellum d) Cerebrum
a) Diencephalon The diencephalon lies beneath the cerebral hemispheres and consists of the thalamus and hypothalamus. The cerebrum is divided into the right and left cerebral hemispheres and consists of four lobes (frontal, parietal, temporal, and occipital). The lobes are composed of a substance known as gray matter, which mediates higher-level functions such as memory, perception, communication, and initiation of voluntary movements. Located between the cerebral cortex and the spinal cord, the brain stem consists of mostly nerve fibers and has three parts: the midbrain, pons, and medulla oblongata. The cerebellum, located behind the brain stem and under the cerebrum, also has two hemispheres. Although the cerebellum does not initiate movement, its primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone.
A nurse cares for a client diagnosed with cranial nerve III disorder. What should the nurse expect to find in the client? a) Drooping of eyelids b) Loss of visual field c) Swelling of the optic nerve d) Inability to close eyes
a) 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.
A client presents to the health care clinic with a 3-day history of fever, chills, neck pain and stiffness, and headache. The nurse observes an elevated temperature of 102.5°F and pain with rotation of the head side to the side and decreased ability to flex the head forward. The nurse recognizes these findings as most likely the onset of what infectious process? a) Meningitis b) Bursitis c) Spondylitis d) Arthritis
a) Meningitis Impaired range of motion and neck pain associated with fever, chills, and a headache may be indicative of a serious infection such as meningitis. Arthritis is inflammation or infection within a joint. Spondylitis is an inflammation of the vertebra. Bursitis is an inflammation in the bursa (small sacs) of synovial fluid in the body.
A nurse is working with a client who suffered nerve damage during surgery for removal of a tumor. The client, who is an artist, lost fine motor control in his hands and can no longer manipulate a paintbrush. Which neural pathway should the nurse suspect to be damaged? a) Pyramidal tract b) Extrapyramidal tract c) Spinothalamic tract d) Posterior columns
a) Pyramidal tract The motor neurons of the pyramidal tract carry impulses to muscles and produce voluntary movements that involve skill and purpose. The extrapyramidal tract conducts impulses to the muscles related to maintenance of muscle tone and body control. Sensations of pain, temperature, and crude and light touch travel by way of the spinothalamic tract, whereas sensations of position, vibration, and fine touch travel by way of the posterior columns.
A nurse is conducting an assessment of an elderly client's nervous system. The client mentions that he has experienced decreased taste and scent sensations recently. Which of the following should the nurse do at this point? a) Record the findings and proceed with the assessment b) Ask the client whether he has experienced a head injury recently c) Perform the Weber test with the client d) Ask the client whether he has experienced sudden numbness or weakness in his face or arms
a) Record the findings and proceed with the assessment Decreased taste and scent sensation occurs normally in older adults. Therefore, the nurse should simply record the finding and proceed with the assessment. A head injury could cause nerve damage that would explain loss of such senses, but the client's age is a much more likely cause. Sudden numbness or weakness in the face or arms is a warning sign of a stroke. The Weber test is used to test a client's hearing.
What task should a nurse ask a client to perform to assess the function of cranial nerve XI? a) shrug shoulders against resistance b) move tongue side to side c) swallow water d) walk in heel-to-toe fashion
a) shrug shoulders against resistance The function of cranial nerve XI can be assessed by asking the client to shrug his or her shoulders against resistance. Asking the client to move the tongue from side to side assesses function of the hypoglossal nerve, Cranial nerve XII. The nurse asks the client to swallow water to assess the function of cranial nerves IX and X. Asking the client to walk in heel-to-toe fashion helps in assessment of balance.
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? a) Tell the client to stand with arms at the sides and note the presence of swaying b) Ask the client to walk in a heel-to-toe fashion and watch for an unsteady gait c) Instruct the client to walk across the floor and note the swinging of the arms d) Have the client stretch out the arms and bring one finger at a time to the nose
b) Ask the client to walk in a heel-to-toe fashion and watch for an unsteady gait To assess the presence of an unsteady gait, the nurse should ask the client to walk in a heel-to-toe fashion and watch for an unsteady gait. This is called tandem walking. Having the client stretch out the arms and bring one finger at a time to the nose tests for coordination. A normal gait should be steady, with the opposite arm swinging as the client walks; however, this observation does not inform the nurse regarding balance. Telling the client to stand with arms at the sides and noting the presence of swaying is the Romberg test, which test for balance but does not assess the client's gait.
A nurse cares for a client who suffered a cerebrovascular accident and demonstrates the inability to speak clearly. The nurse recognizes that injury has occurred to what portion of the brain? a) Temporal lobe b) Broca's area c) Medulla oblongata d) Occipital lobe
b) Broca's area The Broca's area is the center that is responsible for speech. The temporal lobe helps with receiving and interpreting impulses from the ear. The occipital lobe influences the ability to read with understanding and is the primary visual receptor center. The medulla oblongata contains the nuclei for the cranial nerves and has centers that control and regulate respiratory function, heart rate and force, and blood pressure.
The husband of a 65-year-old female tells the nurse, "My wife is having trouble navigating the steps in our home and needs my help to step down off a curb." What part of the nervous system should the nurse assess for a potential source of the problem? a) Temporal lobe b) Cerebellum c) Deep tendon reflexes d) Cranial nerves
b) Cerebellum The cerebellum's primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone. The temporal lobe is part of the cerebrum and helps with receiving and interpreting impulses from the ear. The cranial nerves evolve from the brain or brain stem and transmit motor or sensory messages. Deep tendon reflexes are part of the sensory pathway of the spinal cord, which relay an impulse to the motor nerve and then to the muscles.
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? a) Strike a tuning fork and place it on the top of one foot b) Determine the ability to differentiate hot and cold temperatures c) Use a wisp of cotton to test light touch sensation d) Try another object and test only the upper dermatomes
b) Determine the ability to differentiate hot and cold temperatures If a client cannot correctly differentiate between sharp and dull pain sensations, the nurse should test for temperature sensation. Temperature and pain sensations travel in the lateral spinothalamic tract, thus temperature is only tested if pain sensation is altered. If a client cannot feel pain, feeling a lighter touch is unlikely. Striking a tuning fork and placing it on the top of one foot tests vibratory sensation, not pain or touch. The nurse should not try another object and test on the upper dermatomes, as this would not likely change the results.
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? a) Most clients will hesitate before touching the nose to check their position b) Dominant side will be more coordinated than nondominant side c) As the client repeats the maneuver, movements will be less accurate d) Uncoordinated movements can be expected in the elderly
b) Dominant side will be more coordinated than nondominant side A nurse should ask a client to touch the tip of the nose with the right index finger, then the left. This should be repeated three times. Movements should be smooth and performed without hesitation. The nurse should keep in mind that the client's dominant side will be more coordinated than the nondominant side. The elderly client may be slower but the movement should still be smooth and accurate. Movements should not become less accurate as the client repeats the maneuver.
A nurse performs a neurologic examination on a client who sustained an injury to the spinal cord. What finding should the nurse expect when stroking the bottom of the client's feet? a) Flexion of the toes b) Dorsiflexion of the great toe and fanning of all toes c) Plantar flexion d) Dorsiflexion of the foot
b) Dorsiflexion of the great toe and fanning of all toes An injury to the spinal cord or the brain causes abnormal posturing in the client. This includes dorsiflexion of the great toe and fanning of all toes when the sole of the foot is stroked—a positive Babinski reflex—which is normal in newborns but in adults is an indication of lesions of upper motor neurons or unconscious states resulting from drug and alcohol intoxication, brain injury, or subsequent to an epileptic seizure. In the normal adult, the response to stroking the bottom of the foot is flexion of the toes. Dorsiflexion and plantar flexion are not associated with this reflex.
A nurse assesses a client who presents to the health care clinic with suspected Bell's palsy. What finding should the nurse anticipate on examination? a) Limited lateral gaze of the eyes b) Inability to wrinkle the forehead c) Drooping of the eyelids d) Paralysis of the lower lip
b) Inability to wrinkle the forehead Bell's palsy is a peripheral injury to cranial nerve VII (facial) that causes the inability to close the eyes, wrinkle the forehead, or raise the forehead, along with paralysis of the lower part of the face. Drooping of the eyelids (ptosis) is seen with weak eye muscles such as in myasthenia gravis. Limited lateral gaze of the eyes may indicate increased intracranial pressure. Paralysis of the lower lip is not seen in any common disorder of cranial nerve function.
A nurse is reviewing a client's health record while interviewing her. The nurse sees in the patient's record a score of 3+ on the biceps reflex test from her previous visit. The nurse understands that this finding indicates which of the following? a) Present but decreased b) Increased or brisk, but not pathologic c) Normal d) Exaggerated; indicator of possible upper motor neuron lesion
b) Increased or brisk, but not pathologic Normal reflex scores range from 1+ (present but decreased) to 2+ (normal) to 3+ (increased or brisk, but not pathologic). Absent or markedly decreased (hyporeflexia) deep tendon reflexes (rated 0) occur when a component of the lower motor neurons or reflex arc is impaired and may be seen with spinal cord injuries. Markedly hyperactive (hyperreflexia) deep tendon reflexes (rated 4+) may be seen with lesions of the upper motor neurons and when the higher cortical levels are impaired.
Which of these factors should a nurse include when teaching about risk reduction for cerebrovascular accidents (CVA) to a group of middle-aged adults within the community? Select all that apply a) Reduce smoking b) Limit alcohol to 1 drink per day for women and 2 for men c) Increase protein intake d) Increase estrogen levels e) Lower blood pressure
b) Limit alcohol to 1 drink per day for women and 2 for men, e) Lower blood pressure Risk reduction for a CVA includes controlling blood pressure, stopping smoking (not just reducing it), limiting alcohol to no more than 1 drink per day for women and 2 drinks for men, exercising, lowering cholesterol and fat intake, controlling blood sugar, and avoiding drugs such as cocaine. Increasing estrogen levels and protein intake are not associated with reducing risk for CVAs.
When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence? a) Motor/cerebellar, sensory, reflexes, cranial nerves, mental status b) Mental status, cranial nerves, motor/cerebellar, sensory, reflexes c) Reflexes, sensory, motor/cerebellar, cranial nerves, mental status d) Cranial nerves, motor/cerebellar, sensory, reflexes, mental status
b) Mental status, cranial nerves, motor/cerebellar, sensory, reflexes The nurse should perform the assessment of the nervous system from a level of higher cerebral integration to a level of lower reflexes.
A client presents to the emergency department after being hit in the face with a baseball. The health care provider orders vision testing to be performed to assess the whether the cranial nerves are intact. The nurse should prepare to test which cranial nerves? Select all that apply. a) Abducens b) Oculomotor c) Olfactory d) Trigeminal e) Trochlear
b) Oculomotor, a) Abducens, e) Trochlear The cranial nerves that control motor and sensation of the eyes are II (optic), III (oculomotor), IV (trochlear), and VI (abducens). Cranial nerve I is olfactory, which is associated with the client's sense of smell. The trigeminal is cranial nerve V, which tests the temporal and masseter muscles.
A client has sustained nerve damage as a result of an automobile accident and has lost the ability to sense position, vibration, and fine touch. Which neural pathway should the nurse suspect to be damaged? a) Spinothalamic tract b) Posterior columns c) Pyramidal tract d) Extrapyramidal tract
b) Posterior columns Sensations of pain, temperature, and crude and light touch travel by way of the spinothalamic tract, whereas sensations of position, vibration, and fine touch travel by way of the posterior columns. The motor neurons of the pyramidal tract carry impulses to muscles and produce voluntary movements that involve skill and purpose. The extrapyramidal tract conducts impulses to the muscles related to maintenance of muscle tone and body control.
A nurse is instructing a client who has recently experienced a transient ischemic attack (TIA) on warning signs of a stroke that the client should be aware of in case they occur and she needs to call 911. Which of the following should the nurse mention? Select all that apply. a) Sudden trouble walking, dizziness, loss of balance or coordination b) Sudden numbness or weakness of the face c) Sudden severe headache with no known cause d) Sudden confusion, trouble speaking, or understanding speech e) Sudden chest pain f) Sudden trouble seeing in one or both eyes
b) Sudden numbness or weakness of the face, d) Sudden confusion, trouble speaking, or understanding speech, f) Sudden trouble seeing in one or both eyes, a) Sudden trouble walking, dizziness, loss of balance or coordination, c) Sudden severe headache with no known cause Except for sudden chest pain, which is a symptom of a heart attack, not a stroke, all of the symptoms listed are associated with a stroke.
Which assessment procedure should a nurse institute to test a client for stereognosis? a) With eyes closed, move the client's finger up or down and ask the direction b) With eyes closed, ask the client to identify a familiar object that is placed in their hand c) Ask the client to identify the number of points touched with two ends of an applicator d) Use a blunt instrument to write a number in the client's hand and ask them to identify it
b) With eyes closed, ask the client to identify a familiar object that is placed in their hand To test a client for stereognosis, with the eyes closed, the nurse should ask the client to identify a familiar object that is placed in their hand. To test graphesthesia, the nurse should use a blunt instrument to write a number in the client's hand and ask them to identify it. When testing sensitivity to position, the nurse should ask the client to close their eyes then move the finger up or down and ask the direction it is moved. Asking the client to identify the number of points touched with two ends of an applicator at the same time is two-point discrimination.
What should the nurse assess to test the function of the parietal lobe? a) ability to read b) tactile sensation c) impulses from the ear d) communication
b) tactile sensation To assess the function of the parietal lobe, the nurse should test for tactile sensation. Assessment of the frontal lobe is done by testing the client's communication. To assess the function of the occipital lobe, the nurse should test the ability to read. The function of the temporal lobe is assessed by testing for impulses from the ear.
A nurse observes a client's gait and notes it to be wide based and staggering. The Romberg test results were positive. The nurse recognizes this as what type of abnormal gait? a) Parkinsonian gait b) Footdrop gait c) Cerebellar ataxia d) Spastic hemiparesis
c) Cerebellar ataxia Cerebellar ataxia is recognized by the wide-based and staggering gait. The Romberg test will be positive. This gait can be seen in persons with cerebellar disease or alcohol or drug intoxication. The characteristic abnormality in Parkinson's disease is the shuffling gait with a stooped-over posture and flexion of the hips and knees. Spastic hemiparesis presents with the arm flexed and held close to the body while the client drags the toes and circles the leg outward and forward. Footdrop is seen when the client lifts the foot and knee high with each step, then slaps the foot hard to the ground.
When documenting assessment of the nervous system, a nurse should keep in mind what important principle? a) Label behaviors to prevent errors b) Chart only objective data c) Describe the response d) Validate data before documenting
c) Describe the response When documenting assessment data on the nervous system, it is important for the nurse to describe the response rather than labeling the behavior.
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? a) Vagus (X) b) Hypoglossal (XII) c) Glossopharyngeal (IX) d) Spinal accessory (XI)
c) Glossopharyngeal (IX) The glossopharyngeal nerve (cranial nerve IX) contains sensory fibers for taste on posterior third of tongue and sensory fibers of the pharynx that result in the "gag reflex" when stimulated. The vagus nerve (cranial nerve X) carries sensations from the throat, larynx, heart, lungs, bronchi, gastrointestinal tract, and abdominal viscera and promotes swallowing, talking, and production of digestive juices. The spinal accessory nerve (cranial nerve XI) innervates neck muscles (sternocleidomastoid and trapezius) that promote movement of the shoulders and head rotation and promotes some movement of the larynx. The hypoglossal nerve (cranial nerve XII) innervates tongue muscles that promote the movement of food and talking.
A nurse cares for an elderly client with right side hemiplegia and expressive aphasia. Which deficit should the nurse expect to find in the client? a) Inability to recognize familiar objects b) Rapid speech with no meaning c) Slow speech with appropriate meaning d) Trouble remembering familiar faces
c) Slow speech with appropriate meaning The client diagnosed with right side hemiplegia and expressive aphasia can verbally state wishes. Expressive aphasia is also called Broca's aphasia in which the speech is slowed with difficult articulation but fairly clear meaning. Clients with Wernicke's aphasia have rapid speech with no meaning. Inability to recognize familiar objects is called agnosia. Trouble remembering familiar faces is termed prosophenosia. Both of these conditions can occur with damage to the temporal and occipital lobes of the brain.
Which tests are appropriate for a nurse to perform to test cranial nerve VIII? a) Clench the teeth, light touch, and sharp/dull discrimination b) Gag reflex, rise of the uvula, and ability to swallow c) Whisper, Rinne, and Weber tests d) Smile, frown, show teeth, and puff out cheeks
c) 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 presents to the health care facility for a routine health checkup. The nurse learns that the client has a long history of cardiovascular disease, including hypertension and carotid artery disease. When assessing this client for potential problems in the nervous system, which question by the nurse is appropriate? a) "Do you have trouble hearing people when they talk to you?" b) "Have you noticed any weakness in your muscles?" c) "Have you noticed any changes in your vision?" d) "Are you having any dizziness or lightheadedness?"
d) "Are you having any dizziness or lightheadedness?" Clients with carotid artery disease may experience dizziness or lightheadedness, especially with ambulation because of the increased difficulty in circulating enough blood and oxygen to the brain. Trouble hearing and changes in vision may signal cranial nerve dysfunction. Weakness in the muscles of the extremities is an indication of a CVA or nerve injury.
A nurse performs a two-point discrimination test on a client who was in an automobile accident to assess for the presence of a lesion of the sensory cortex. The nurse touches the client's body at various sites on his right side with the two points of EKG calipers. Which finding, stated as the distance between the two points at which the client can no longer distinguish the two points as separate, would indicate an abnormal response on the part of the client? a) 45 mm on the chest b) 6 mm at the fingertips c) 40 mm on the upper arm d) 20 mm on the dorsal hand
d) 20 mm on the dorsal hand Normal two-point discrimination findings on the right side include the following: 6 mm at the fingertips, 15 mm on the dorsal hand, 45 mm on the chest, and 40 mm on the upper arm. Thus, the finding of 20 mm on the dorsal hand is abnormal and may indicate a lesion of the sensory cortex.
A client sustains an injury to the brain stem. What is the most important assessment parameter that the nurse should perform for this client? a) Movement of all extremities b) Level of consciousness c) Sensation in extremities d) Depth of respirations
d) Depth of respirations The brain stem controls many functions. The medulla oblongata contains the nuclei for the cranial nerves and has centers that control and regulate respiratory function, heart rate and force, and blood pressure. Movement and sensation of the extremities is controlled by various functions of the nervous system. Level of consciousness occurs when the brain does not receive enough oxygen.
When testing the biceps reflex, what type of response should the nurse expect if normal? a) Forearm flexes and supinates b) Elbow extends and muscle contracts c) Forearm adducts and wrist rotates d) Elbow flexes and muscle contracts
d) Elbow flexes and muscle contracts To elicit the biceps reflex, the nurse should ask the client to partially bend the arm at elbow with palm up. The nurse places the thumb over the biceps and strikes the thumb with the reflex hammer. The normal finding with this reflex is the elbow flexes and contraction of the biceps muscle occurs. When assessing the brachioradialis reflex, the normal finding is flexion and supination of the forearm. The other two are not findings elicited with upper extremity reflexes.
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? a) V b) II c) I d) III
d) III Cranial nerve III is responsible for the damage to pupillary response. Cranial nerve I disorders cause damage to sense of smell. Cranial nerve V is responsible for the function of masseter muscle contraction. Cranial nerve II disorders damage vision due to retinal detachment or due to a lesion in the nerve.
A nurse is performing a test of cranial nerve XII (hypoglossal) on an elderly client. When the client protrudes her tongue for the test, the tongue moves in and out uncontrollably. Which of the following should the nurse most suspect? a) Injury of the central spinal cord b) Peripheral nerve disease c) Cerebrovascular accident d) Intentional tremor
d) Intentional tremor Older adults may experience intentional tremors (tremors that occur with intentional movements). This may be seen with extending the hands, head nodding for "yes or no," or extending one's tongue, which may protrude back and forth. Such tremors are not associated with disease, but they may cause embarrassment or emotional distress. Fasciculations and atrophy of the tongue may be seen with peripheral nerve disease. Injury of the central spinal cord is associated with extremity weakness. Sudden numbness and weakness of the muscles of the face, arms, and legs are associated with cerebrovascular accident (stroke).
A nurse performs a neurological examination on a client who sustained an injury to the spinal cord. What finding should the nurse expect when stroking the bottom of the client's feet? a) Flexion of the toes b) Fanning of the toes c) Dorsiflexion d) Plantar flexion
d) Plantar flexion An injury to the spinal cord or the brain causes abnormal posturing in the client. This includes plantar flexion of the feet when stroked. The Babinski reflex in newborns is when the bottom of the foot is stroked, the toes fan out. In the normal adult, the response to stroking the bottom of the foot is flexion of the toes. Dorsiflexion is part of the range of motion for the foot.
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? a) Risk for Altered Skin Integrity b) Impaired Verbal Communication c) Unilateral Neglect d) Risk for Aspiration
d) Risk for Aspiration Due to the client's decreased mental status and slurred speech, he is at greatest risk for aspiration. Measures must be implemented by the nurse to prevent aspiration, such as NPO, elevating the head of bed, and assessment of lung sounds. Impaired Verbal Communication is a psychosocial issue, and physiologic problems take precedence over mental health at this point in time. Unilateral neglect is not as much of a priority as is the risk for aspiration. There is no indication that there is a risk for altered skin integrity
A nurse is working with a client who is victim of a gun shooting. The client has an increased pulse rate and pupil dilation and is clearly in stress. The nurse recognizes the "fight-or-flight" response in this client and understands that this represents an activation of which of the following? a) Somatic nervous system b) Central nervous system c) Parasympathetic nervous system d) Sympathetic nervous system
d) Sympathetic nervous system The sympathetic nervous system ("fight-or-flight" system) is activated during stress and elicits responses such as decreased gastric secretions, bronchiole dilatation, increased pulse rate, and pupil dilatation. The parasympathetic nervous system functions to restore and maintain normal body functions, for example, by decreasing heart rate. The somatic nervous system mediates conscious, or voluntary, activities, whereas the autonomic nervous system (comprising the sympathetic and parasympathetic systems) mediates unconscious, or involuntary, activities. The central nervous system (CNS) encompasses the brain and spinal cord, which are covered by meninges, three layers of connective tissue that protect and nourish the CNS.
Which action by a nurse demonstrates the correct technique to use the reflex hammer? a) Strike the tendon then palpate for a response b) Instruct the client to tense the muscles before striking c) Tap the tendon gently to avoid pain and tingling d) Use rapid wrist movement and strike the tendon
d) Use rapid wrist movement and strike the tendon When using a reflex hammer, the nurse should use rapid wrist movement and strike the tendon briskly. Tapping gently will not cause the tendon to shorten and the reflex will not occur. The tendon should be palpated before striking the hammer to know the area. The nurse should encourage the client to relax the muscles because tenseness can inhibit a normal response.
A client presents to the health care clinic with reports of difficulty swallowing. Which cranial nerves will provide the nurse with information related to the problem? Select all that apply. a) Spinal accessory b) Trochlear c) Glossopharyngeal d) Abducens e) Hypoglossal f) Vagus
f) Vagus, e) Hypoglossal, c) Glossopharyngeal Difficulty swallowing can be a finding with CVA, Parkinson's disease, myasthenia gravis, Gullian Barre, or cranial nerve dysfunction. The cranial nerves that the nurse should be aware of are IX (glossopharyngeal), X (vagus), and XII (hypoglossal). Cranial nerve VI (abducens) controls lateral eye movement. Cranial nerve XI (spinal accessory) innervates the neck and shoulder muscles.
