Chapter 36: Introduction to Nervous System

What neurologic assessment should the nurse perform to gauge the client's function of cranial nerve I? a. Have the client identify familiar odors with the eyes closed. b. Assess papillary reflex. c. Utilize the Snellen chart. d. Test for air and bone conduction (Rinne test).

a Cranial nerve I is the olfactory nerve. The client's sense of smell could be assessed by asking him or her to identify common odors. Assessment of papillary reflex does not address the olfactory function of cranial nerve I. The Snellen chart would be used to assess cranial nerve II (optic).

In the divisions of the nervous system, the basic structure is the neuron. The function of the neuron is determined by the direction of impulse transmission. Which part of the neuron is responsible for conducting impulses to the cell body? a. dendrites b. efferent nerve fibers c. axon d. nucleus

a Dendrites conduct impulses to the cell body and are called afferent ("to" or "toward") nerve fibers.

The brain is a complex structure and is divided into three parts: the cerebrum, the cerebellum, and the brain stem. The brain stem consists of the midbrain, pons, and medulla oblongata. Which part of the brain contains regulatory centers for heartbeat, vasomotor activity, and breathing? a. medulla oblongata b. midbrain c. pons d. cerebral cortex

a The medulla oblongata contains vital centers concerned with respiration, heartbeat, and vasomotor activity (the control of smooth muscle activity in blood vessel walls).

A client has been exhibiting neurological symptoms for several weeks and the neurologist is admitting the client to the hospital for extensive testing. Since diagnostics have not yet revealed the cause of the symptoms, which client statement would indicate the need for further client education? a. "It's good to know the continual tingling in my fingers and toes is not connected with my nervous system!" b. "I need to be careful with my allergy to seafood!" c. "There are several types of tests to see what's causing the tingling in my fingers and toes." d. All of the comments indicate need for further client education.

a The nervous system consists of the brain, spinal cord, and peripheral nerves.

A typical spinal cord functions as a "highway" for sensory and descending motor neurons, providing conduction of impulses to and from the brain. The spinal cord is surrounded and protected by bony vertebrae, and ends between the: a. first and second lumbar vertebrae. b. first and second cervical vertebrae. c. first and second thoracic vertebrae. d. fourth and fifth thoracic vertebrae.

a The spinal cord ends between the first and second lumbar vertebrae, where it divides into smaller sections called the cauda equine.

Cerebrospinal fluid (CSF) is manufactured in the ventricles and constantly circulates around the brain and spinal cord. The CSF functions as a cushion to protect structures and maintain relatively consistent intracranial pressure. Where does CSF circulate? a. subarachnoid space b. subdural space c. subpial space d. arachnoid space

a The ventricles manufacture and absorb cerebrospinal fluid (CSF), which constantly circulates in the subarachnoid space of the brain and spinal cord.

The Glasgow Coma Scale is a common screening tool used for patients with a head injury. During the physical exam, the nurse documents that the patient is able to spontaneously open her eyes, obey verbal commands, and is oriented. The nurse records the highest score of: a. 20 b. 15 c. 10 d. 5

b A Glasgow Come Scale (GCS) score is based on three patient responses: eye opening, motor response, and verbal response. The patient receives a score for his best response in each area, and the three scores are added together. The total score will range from 3 to 15; the higher the number, the better. A score of 8 or lower usually indicates coma.

The nurse is caring for a patient who was involved in a motor vehicle accident and sustained a head injury. When assessing deep tendon reflexes (DTR), the nurse observes diminished or hypoactive reflexes. How will the nurse document this finding? a. 0 b. 1+ c. 2+ d. 3+

b Diminished or hypoactive DTRs are indicated by a score of 1+, no response by a score of 0, a normal response by a score of 2+, and an increased response by a score of 3+.

The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart? a. CN I b. CN II c. CN III d. CN IV

b The nurse assesses vision and thus the optic nerve (cranial nerve II) by use of a Snellen eye chart.

The nurse caring for an 80-year-old client knows that the client has a pre-existing history of dulled tactile sensation. The nurse should first consider what possible cause for this client's diminished tactile sensation? a. Damage to cranial nerve VIII b. Adverse medication effects c. Age-related neurologic changes d. An undiagnosed cerebrovascular disease in early adulthood

c Tactile sensation is dulled in the elderly person due to a decrease in the number of sensory receptors. While thorough assessment is necessary, it is possible that this change is unrelated to pathophysiologic processes.

Which of the following cranial nerves is responsible for salivation, tearing, taste, and sensation in the ear? a. Vestibulocochlear b. Oculomotor c. Facial d. Trigeminal

c The vestibulocochlear (VIII) cranial nerve is responsible for hearing and equilibrium. The oculomotor (III) cranial nerve is responsible for the muscles that move the eye and lid, pupillary constriction, and lens accommodation. The trigeminal (V) cranial nerve is responsible for facial sensation, corneal reflex, and mastication. The facial (VII) nerve controls facial expression and muscle movement, salivation and tearing, taste, and sensation in the ear.

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities? a. Decerebrate b. Decorticate c. Flaccid d. Normal

b Decorticate posturing is an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities and extension of the lower extremities. Decerebration is an abnormal body posture associated with a severe brain injury, characterized by extreme extension of the upper and lower extremities. Flaccidity occurs when the client has no motor function, is limp, and lacks motor tone.

The nurse is caring for a client who is to have a lumbar puncture. What are the lowest vertebrae that contain the spinal cord? a. coccyx b. second lumbar vertebrae c. eleventh thoracic vertebrae d. fifth lumbar vertebrae

b The spinal cord ends between the first and second lumbar vertebrae.

The nurse is assessing the client's mental status . Which question will the nurse include in the assessment? a. "Who is the president of the United States?" b. "Can you write your name on this piece of paper?" c. "Can you count backward from 100?" d. "Are you having hallucinations now?"

a Assessing orientation to time, place, and person assists in evaluating mental status. Does the client know what day it is, what year it is, and the name of the president of the United States? Is the client aware of where he or she is? Is the client aware of who the examiner is and why he or she is in the room? "Can you write your name on this piece of paper?" will assess language ability. "Can you count backward from 100?" assesses the client's intellectual function. "Are you having hallucinations?" assesses the client's thought content.

A patient arrives to have an MRI done in the outpatient department. What information provided by the patient warrants further assessment to prevent complications related to the MRI? a. "I am trying to quit smoking and have a patch on." b. "I have been trying to get an appointment for so long." c. "I have not had anything to eat or drink since 3 hours ago." d. "My legs go numb sometimes when I sit too long."

a Before the patient enters the room where the MRI is to be performed, all metal objects and credit cards (the magnetic field can erase them) must be removed. This includes medication patches that have a metal backing and metallic lead wires; these can cause burns if not removed (Bremner, 2005).

The brain is a complex structure and is divided into three parts: the cerebrum, the cerebellum, and the brain stem. The cerebrum is divided into two hemispheres and is further divided into four lobes per hemisphere. Which section of the brain controls and coordinates muscle movements? a. cerebellum b. cerebrum c. brain stem d. midbrain

a The cerebellum, which is located behind and below the cerebrum, controls and coordinates muscle movement.

The provider orders the Romberg test for a patient. The nurse tells the patient that the provider wants to evaluate his equilibrium by assessing which cranial nerve? a. III b. VII c. VIII d. X

c Cranial nerve VIII (acoustic) can be checked to assess equilibrium status.

A client for whom the nurse is caring has positron emission tomography (PET) scheduled. In preparation, what should the nurse explain to the client? a. The test will temporarily limit blood flow through the brain. b. An allergy to iodine precludes getting the radio-opaque dye. c. The client will need to endure loud noises during the test. d. The test may result in dizziness or lightheadedness.

d Key nursing interventions for PET scan include explaining the test and teaching the client about inhalation techniques and the sensations (e.g., dizziness, lightheadedness, and headache) that may occur. A PET scan does not impede blood flow through the brain. An allergy to iodine precludes the dye for an MRI, and loud noise is heard in an MRI.

The nurse conducts the Romberg test on a client by asking the client to stand with feet close together and eyes closed. As a result of this posture, the client suddenly sways to one side and nearly falls. The nurse interprets this result as a: a. positive Romberg test, indicating a problem with equilibrium. b. positive Romberg test, indicating a problem with LOC. c. negative Romberg test, indicating a problem with body mass. d. negative Romberg test, indicating a problem with vision.

a If the client sways and tends to fall during the Romberg test, it indicates a positive Romberg test. This means the client has a problem with equilibrium. The examiner or the nurse should stand fairly close to the client during the test to prevent the client from falling. The Romberg test is used to assess the motor function of the client including muscle movement, size, tone, strength, and coordination.

The nurse is planning the care of a client with Parkinson disease. The nurse should be aware that treatment will focus on what pathophysiologic phenomenon? a. Premature degradation of acetylcholine b. Decreased availability of dopamine c. Insufficient synthesis of epinephrine d. Delayed reuptake of serotonin

b Parkinson disease develops from decreased availability of dopamine, not acetylcholine, epinephrine, or serotonin.

Which cerebral lobes is the largest and controls abstract thought? a. Temporal b. Frontal c. Parietal d. Occipital

b The frontal lobe also controls information storage or memory and motor function. The temporal lobe contains the auditory receptive area. The parietal lobe contains the primary sensory cortex, which analyzes sensory information and relays interpretation to the thalamus and other cortical areas. The occipital lobe is responsible for visual interpretation.

There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected with decreased visual fields. a. Cranial nerve I b. Cranial nerve II c. Cranial nerve III d. Cranial nerve IV

b The three sensory cranial nerves are I, II and VIII. Cranial nerve II (optic) is affected with decreased visual fields and acuity.

When the nurse observes that the client has extension and external rotation of the arms and wrists and plantar flexion of the feet, the nurse records the client's posture as a. normal. b. flaccid. c. decorticate. d. decerebrate.

d Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The client's head and neck arch backward, and the muscles are rigid. In decorticate posturing, which results from damage to the nerve pathway between the brain and spinal cord and is also very serious, the client has flexion and internal rotation of the arms and wrists, as well as extension, internal rotation, and plantar flexion of the feet.

To assess a client's cranial nerve function, a nurse should assess: a. hand grip. b. orientation to person, time, and place. c. arm drifting. d. gag reflex.

d The gag reflex is governed by the glossopharyngeal nerve, cranial nerve IX. The other choices would not be involved in a cranial nerve assessment. Hand grip and arm drifting are part of motor function assessment. Orientation is an assessment parameter related to a mental status examination.

A nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? a. comatose b. somnolence c. stupor d. normal

a The GSC is used to measure the LOC. The scale consists of three parts: eye opening response, best verbal response, and best motor response. A normal response is 15. A score of 7 or less is considered comatose. Therefore, a score of 6 indicates the client is in a state of coma and not in any other state such as stupor or somnolence. The evaluations are recorded on a graphic sheet where connecting lines show an increase or decrease in the LOC.

Which lobe of the brain is responsible for concentration and abstract thought? a. Frontal b. Parietal c. Temporal d. Occipital

a The major functions of the frontal lobe are concentration, abstract thought, information storage or memory, and motor function. The parietal lobe analyzes sensory information such as pressure, vibration, pain, and temperature. The occipital lobe is the primary visual cortex. The temporal lobe contains the auditory receptive areas located around the temples.

Axons in the central and peripheral nervous systems may, or may not, be myelinated. Those that are myelinated are called white nerve fibers; those that are not are called gray nerve fibers. What is the function of myelination? a. insulate electrical conduction b. decrease impulse conduction speed c. increase impulse conduction speed d. inconclusive function, still being investigated

a Myelin serves as an insulating substance for the axon that confines the electrical conduction without allowing it to scatter.

A client is being given a medication that stimulates the parasympathetic system. Following administration of this medication, the nurse should anticipate what effect? a. Constricted pupils b. Dilated bronchioles c. Decreased peristaltic movement d. Relaxed muscular walls of the urinary bladder

a Parasympathetic stimulation results in constricted pupils, constricted bronchioles, increased peristaltic movement, and contracted muscular walls of the urinary bladder.

A patient has been brought to the emergency department (ED) with signs and symptoms of a stroke and a stat computed tomography (CT) head scan has been ordered. The ED nurse should know that the image that results from CT indicates distinguishing differences based on which of the following variables? a. Proximity to the CT scanner b. Variations in tissue density c. Metabolic activity d. Oxygen consumption

b CT scanning makes use of a narrow X-ray beam to scan the body part in successive layers. The images provide cross-sectional views of the brain, with distinguishing differences in tissue densities of the skull, cortex, subcortical structures, and ventricles.

The nurse is scoring the client's level of consciousness using the Glasgow Coma Scale. Which score would indicate that the client is in comatose state? a. D+ b. 17 or lower c. 7 d. D

c The GCS is a numeric scale with a maximum score of 15. A score of 7 or less is considered a coma .

A client is currently being stimulated by the parasympathetic nervous system. What effect will this nervous stimulation have on the client's bladder? a. Urinary retention b. Bladder spasms c. Urge incontinence d. Bladder contract

d The parasympathetic division of the nervous system causes contraction (stimulation) of the urinary bladder muscles whereas the sympathetic division produces relaxation (inhibition) of the urinary bladder.

A nurse is discussing a lumbar puncture with a nursing student who observed the procedure. The student noticed that the cerebrospinal fluid was blood tinged and asks what that means. The correct reply is which of the following? a. "It can mean a traumatic puncture or a subarachnoid bleed." b. "It can mean a bleed around the hypothalamus or damage from the needle." c. "It can mean the spinal cord was damaged or a traumatic puncture." d. "It can mean a subarachnoid bleed or damage to the spinal cord."

a The needle is inserted below the level of the spinal cord, which prevents damage to the cord. The cerebral spinal fluid (CSF) should be clear and colorless. Pink or bloody CSF may indicate a subarachnoid bleed or local trauma from the puncture. The hypothalamus is located deep inside the brain and does not affect the color of the CSF.

When completing a neurologic examination on a client, which question is most essential to evaluate the accuracy of the data? a. When, if any, was your last narcotic use? b. Do you have any history of forgetfulness? c. Have you been diagnosed with any mental health issues? d. Have you experienced any unusual sensations?

a When completing a neurologic exam, it is essential to assess the use of morphine, heroin, narcotic, or central nervous system depressant because these affect the results of a neurologic examination. These types of drugs decrease the level of consciousness. The nurse can observe forgetfulness and mental status. Experiencing unusual sensations is good subjective data to have but is not essential to evaluate the accuracy of objective data.

The nurse is caring for a client who exhibits abnormal results of the Weber test and Rinne test. The nurse should suspect dysfunction involving what cranial nerve? a. Trigeminal b. Acoustic c. Hypoglossal d. Trochlear

b Abnormal hearing can correlate with damage to cranial nerve VIII (acoustic). The acoustic nerve functions in hearing and equilibrium. The trigeminal nerve functions in facial sensation, corneal reflex, and chewing. The hypoglossal nerve moves the tongue. The trochlear nerve controls muscles that move the eye.

A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize what action? a. Withholding stimulants 24 to 48 hours prior to exam b. Removing all metal-containing objects c. Instructing the patient to void prior to the MRI d. Initiating an IV line for administration of contrast

b Client preparation for an MRI consists of removing all metal-containing objects prior to the examination. Withholding stimulants would not affect an MRI; this relates to an electroencephalography (EEG). Instructing the client to void is client preparation for a lumbar puncture. Initiating an IV line for administration of contrast would be done if the client was having a CT scan with contrast.

The nurse is performing a neurologic assessment of a client whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the client's level of consciousness (LOC)? a. Assess the client's vital signs and correlate these with the client's baselines. b. Assess the client's eye opening and response to stimuli. c. Document that the client currently lacks a level of consciousness. d. Facilitate diagnostic testing in an effort to obtain objective data.

b If the client is not alert or able to follow commands, the examiner observes for eye opening; verbal response and motor response to stimuli, if any; and the type of stimuli needed to obtain a response. Vital signs and diagnostic testing are appropriate, but neither will allow the nurse to gauge the client's LOC. Inability to follow commands does not necessarily denote an absolute lack of consciousness.

The nurse is caring for a stuporous client in the intensive care unit. Which assessment finding is documented to reflect an improvement in the client's level of consciousness? a. conscious b. somnolent c. stuporous d. semi-comatose

b Somnolent or lethargic means that the client is drowsy or sleepy at inappropriate times. This is an improvement from the stuporous state, which includes arousing the client only with vigorous and repeated stimulation. A client that is conscious is alert and responds to stimulation immediately. A client is documented as semi-comatose when the client only responds to superficial, relatively mild painful stimuli.

A patient has suffered cerebellar trauma after falling off of a ladder. The patient has been stabilized and is now receiving care on a neurological unit. When planning this patient's care, what nursing diagnosis is most likely to result from an injury to this part of the brain? a. Risk for aspiration b. Risk for falls c. Risk for ineffective thermoregulation d. Risk for ineffective breathing pattern

b The cerebellum is largely responsible for coordination of all movement. Injury thus results in a significant risk for falls. The cerebellum does not coordinate thermoregulation, swallowing, or respiration.

A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first? a. Maintain the client NPO for 6 hours before the test. b. Obtain a blood sample to evaluate BUN and creatinine concentrations. c. Assess the client for medication allergies. d. Obtain two large-bore IV lines.

c If a contrast agent is used, the client must be assessed before the CT scan for an iodine/shellfish allergy, because the contrast agent used may be iodine based. If the client has no allergies to iodine, then kidney function must also be evaluated, as the contrast material is cleared through the kidneys. A suitable IV line for contrast injection and a period of fasting (usually 4 hours) are required before the study. Clients who receive an IV contrast agent are monitored during and after the procedure for allergic reactions and changes in kidney function.

A client in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is which of the following? a. Cerebellum b. Thalamus c. Hypothalamus d. Midbrain

c The hypothalamus plays an important role in the endocrine system because it regulates the pituitary secretion of hormones that influence metabolism, reproduction, stress response, and urine production. It works with the pituitary to maintain fluid balance through hormonal release and maintains temperature regulation by promoting vasoconstriction or vasodilatation. The cerebellum, thalamus, and midbrain are not directly involved in temperature regulation.

A nurse is performing a neurologic assessment on a client. The nurse observes the client's tongue for symmetry, tremors, and strength, and assesses the client's speech. Which cranial nerve is the nurse assessing? a. IV b. IX c. VI d. XII

d Cranial nerve XII, the hypoglossal nerve, controls tongue movements involved in swallowing and speech. The tongue should be midline, symmetrical, and free from tremors and fasciculations. The nurse tests tongue strength by asking the client to push his tongue against his cheek as the nurse applies resistance. To test the client's speech, the nurse may ask him to repeat the sentence, "Round the rugged rock that ragged rascal ran." The trochlear nerve (IV) is responsible for extraocular movement (inferior medial). The glossopharyngeal nerve (IX) is responsible for swallowing movements and throat sensations. It's also responsible for taste in the posterior third of the tongue. The abducent nerves (VI) are responsible for lateral extraocular movements.

During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates: a. cranial nerves I and II. b. cranial nerves III and V. c. cranial nerves VI and VIII. d. cranial nerves IX and X.

d Swallowing is a motor function of cranial nerves IX and X. Cranial nerves I, II, and VIII don't possess motor functions. The motor functions of cranial nerve III include extraocular eye movement, eyelid elevation, and pupil constriction. The motor function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement.

A nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm? a. milligram b. electroencephalogram c. echoencephalography d. cerebral angiography

d The nurse would anticipate a cerebral angiography, which detects distortion of the cerebral arteries and veins . A milligram detects abnormalities of the spinal canal. An electroencephalogram records electrical impulses of the brain. An echoencephalography is an ultrasound of the structures of the brain.

A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution? a. Hot or cold packs b. Analgesics c. Anti-inflammatory medications d. Whirlpool baths

a Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used. The older client may be burned or suffer frostbite before being aware of any discomfort. Any medication is used with caution in the elderly, but not because of the decreased sense of heat or cold. Whirlpool baths are generally not a routine treatment prescribed for the elderly.

A patient who has suffered a stroke is unable to maintain respiration and is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe? a. Frontal lobe b. Occipital lobe c. Parietal lobe d. Brain stem

d The brain stem consists of the midbrain, pons, and medulla oblongata (see Fig. 65-2). Portions of the pons help regulate respiration. Motor fibers from the brain to the spinal cord and sensory fibers from the spinal cord to the brain are located in the medulla. Reflex centers for respiration, blood pressure, heart rate, coughing, vomiting, swallowing, and sneezing are located in the medulla.

The nurse is caring for a client with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the client's neurologic assessment? a. Decreased muscle tone b. Flaccid paralysis c. Loss of voluntary control of movement d. Slow reflexes

c Upper motor neuron lesions do not cause muscle atrophy, flaccid paralysis, or slow reflexes. However, upper motor neuron lesions normally cause loss of voluntary control.

A client is brought to the ER following a motor vehicle accident in which he sustained head trauma. Preliminary assessment reveals a vision deficit in the client's left eye. The nurse should associate this abnormal finding with trauma to what cerebral lobe? a. Temporal b. Occipital c. Parietal d. Frontal

b The posterior lobe of the cerebral hemisphere is responsible for visual interpretation. The temporal lobe contains the auditory receptive areas. The parietal lobe contains the primary sensory cortex, and is essential to an individual's awareness of the body in space, as well as orientation in space and spatial relations. The frontal lobe functions in concentration, abstract thought, information storage or memory, and motor function.

Which of the following areas of the brain are responsible for temperature regulation? a. Hypothalamus b. Thalamus c. Pons d. Medulla

a The hypothalamus also controls and regulates the autonomic nervous system and maintains temperature by promoting vasoconstriction or vasodilation. The thalamus acts primarily as a relay station for all sensation except smell. The medulla and pons are essential for respiratory function.

A client has undergone a lumbar puncture for a neurological assessment. The client is put under the post-procedure care of a nurse. Which important post-procedure nursing interventions should be performed to ensure maximum comfort for the client? Select all that apply. a. Position the client flat for at least three hours or as directed by the physician. b. Encourage a liberal fluid intake for the client. c. Shampoo the client's hair with warm water. d. Keep the room brightly lit and play soothing music in the background.

a, b The nurse should encourage the client to take liberal fluids and inspect the injection site for swelling or hematoma.

The neurologic nurse is testing the function of a client's cerebellum and basal ganglia. What action will most accurately test these structures? a. Have the client identify the location of a cotton swab on his or her skin with the eyes closed. b. Elicit the client's response to a hypothetical problem. c. Ask the client to close his or her eyes and discern between hot and cold stimuli. d. Guide the client through the performance of rapid, alternating movements.

d Cerebellar and basal ganglia influence on the motor system is reflected in balance control and coordination. Coordination in the hands and upper extremities is tested by having the client perform rapid, alternating movements and point-to-point testing. The cerebellum and basal ganglia do not mediate cutaneous sensation or judgment.

The nurse is preparing a client for a neurological examination by the physician and explains tests the physician will be doing, including the Romberg test. The client asks the purpose of this particular test. The correct reply by the nurse is which of the following? a. "It is a test for balance." b. "It is a test for coordination." c. "It is a test for muscle strength." d. "It is a test for motor ability."

a The Romberg test screens for balance. The client stands with feet together and arms at the side, first with eyes open and then with both eyes closed for 20 to 30 seconds. Slight swaying is normal, but a loss of balance is abnormal and is considered a positive Romberg test.

The nurse is completing the physical assessment of a client suspected of a neurological disorder. The client reports having recently suffered a head trauma. In such a case, the nurse should: a. not move or manipulate the client's head while assessing for bleeding or swelling. b. explain the procedure of head assessment to the client before doing the assessment. c. only move the client's head with the help of an assistant. d. make the client sit in a chair and then assess his or her head for bleeding or swelling.

a The nurse evaluates the client's body posture and any abnormal position of the head, neck, trunk, or extremities. The nurse carefully examines the head for bleeding, swelling, or wounds. The nurse does not move or manipulate the client's head during physical assessment, especially if there is a recent history of trauma.

The nurse is doing an initial assessment on a client newly admitted to the unit with a diagnosis of cerebrovascular disease. The client has difficulty copying a figure that the nurse has drawn and is diagnosed with visual receptive aphasia. What brain region is primarily involved in this client's deficit? a. Temporal lobe b. Parietal—occipital area c. Inferior-posterior frontal areas d. Posterior frontal area

b Difficulty copying a figure that the nurse has drawn would be considered visual receptive aphasia, which involves the parietal—occipital area. Expressive aphasia, the inability to express oneself, is often associated with damage to the frontal area. Receptive aphasia, the inability to understand what someone else is saying, is often associated with damage to the temporal lobe area.

A patient recently noted difficulty maintaining his balance and controlling fine movements. The nurse explains that the provider will order diagnostic studies for the part of his brain known as the: a. Midbrain. b. Cerebellum. c. Pons. d. Medulla oblongata.

b The cerebellum is largely responsible for coordination of all movement. It also controls fine movement, balance, position (postural) sense or proprioception (awareness of where each part of the body is), and integration of sensory input.

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain? a. Frontal b. Occipital c. Temporal d. Parietal

b The occipital lobe is responsible for interpreting visual stimuli. The frontal lobe influences personality, judgment, abstract reasoning, social behavior, language expression, and movement. The temporal lobe controls hearing, language comprehension, and storage and memory recall (although memory recall is also stored throughout the brain). The parietal lobe interprets and integrates sensations, including pain, temperature, and touch; it also interprets size, shape, distance, and texture.

The nurse has admitted a new client to the unit. One of the client's admitting orders is for an adrenergic medication. The nurse knows that this medication will have what effect on the circulatory system? a. Thin, watery saliva b. Increased heart rate c. Decreased BP d. Constricted bronchioles

b The term "adrenergic" refers to the sympathetic nervous system. Sympathetic effects include an increased rate and force of the heartbeat. Cholinergic effects, which correspond to the parasympathetic division of the autonomic nervous system, include thin, watery saliva, decreased rate and force of heartbeat, and decreased BP.

What safety actions does the nurse need to take for a client receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)? a. Securely fasten the client's portable oxygen tank to the bottom of the MRI table after the client has been positioned on the top of the MRI table b. Check the client's oxygen saturation level using a pulse oximeter after the client has been placed on the MRI table c. Note that no special safety actions need to be taken d. Ensure that no client care equipment containing metal enters the room where the MRI is located.

d For client safety the nurse must make sure no client care equipment that contains metal or metal parts (e.g., portable oxygen tanks) enters the room where the MRI is located. The magnetic field generated by the unit is so strong that any metal-containing items will be strongly attracted and can literally be pulled away with such great force that they can fly like projectiles toward the magnet.

A client exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most plausible cause of this client's health problem? a. Cerebellar dysfunction b. A lesion in the pons c. Dysfunction of the medulla d. A hemorrhage in the midbrain

a The cerebellum controls fine movement, balance, position sense, and integration of sensory input. Portions of the pons control the heart, respiration, and blood pressure. Cranial nerves IX to XII connect to the brain in the medulla. Cranial nerves III and IV originate in the midbrain.

A client is scheduled for a myelogram and the nurse explains to the client that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests? a. Lumbar puncture b. MRI c. Cerebral angiography d. EEG

a A myelogram is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. Client preparation for a myelogram would be similar to that for lumbar puncture. The other listed diagnostic tests do not involve lumbar puncture.

Cranial nerve IX is also known as which of the following? a. Glossopharyngeal b. Vagus c. Spinal accessory d. Hypoglossal

a Cranial nerve IX is the glossopharyngeal nerve. The vagus nerve is cranial nerve X. Cranial nerve XII is the hypoglossal nerve. The spinal accessory is the cranial nerve XI.

A patient has been diagnosed with damage to Broca's area of the left frontal lobe. To document the extent of damage, the nurse would assess the patient's: a. Speech. b. Vision. c. Hearing. d. Balance.

a The motor strip, which lies in the frontal lobe, anterior to the central sulcus, is responsible for muscle movement. It also contains Broca's area (left frontal lobe region in most people), critical for motor control of speech.

The nurse is assessing the pupils of a patient who has had a head injury. What does the nurse recognize as a parasympathetic effect? a. Dilated pupils b. Constricted pupils c. One pupil is dilated and the opposite pupil is normal d. Roth's spots

b Constricted pupils are a parasympathetic effect; dilated pupils are a sympathetic effect.

A 78-year-old resident of a long-term care facility has left the majority of his supper tray untouched, and the nurse has asked him about the reason for this. The resident states, "For a long time now, food just doesn't taste as well as it used to." The nurse should be aware that the etiology of this problem is most likely to involve: a. Cranial nerve dysfunction b. An upper motor neuron lesion c. Age-related changes to the neurological system d. The development of a posterior spinal nerve lesion

c Decreased taste sensation is a normal, age-related change and is rarely the result of pathophysiological processes.

A client is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the client in preparation for this test? a. "No metal objects can enter the procedure room." b. "You need to fast for 8 hours prior to the test." c. "You will need to lie still throughout the procedure." d. "There will be a lot of noise during the test."

c Preparation for CT scanning includes teaching the client about the need to lie quietly throughout the procedure. If the client were having an MRI, metal and noise would be appropriate teaching topics. There is no need to fast prior to a CT scan of the brain.

Which cerebral lobe contains the auditory receptive areas? a. Frontal b. Parietal c. Occipital d. Temporal

d The temporal lobe plays the most dominant role of any area of the cortex in cerebration. The frontal lobe, the largest lobe, controls concentration, abstract thought, information storage or memory, and motor function. The parietal lobe contains the primary sensory cortex, which analyzes sensory information and relays interpretation to the thalamus and other cortical areas. The occipital lobe is responsible for visual interpretation.

A nurse is completing a neurological assessment and determines that the client has significant visual deficits. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit? a. frontal b. parietal c. temporal d. occipital

d The vision center is located in the occipital lobe. There is little that may interfere with the visual process in the other lobes of the brain.

The family nurse practitioner is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly? a. moving the head toward both sides b. lightly tapping the lower portion of the neck to detect sensation c. moving the head and chin toward the chest d. gently pressing the bones on the neck

c The neck is examined for stiffness or abnormal position. The presence of rigidity is assessed by moving the head and chin toward the chest. The nurse should not maneuver the neck if a head or neck injury is suspected or known. The neck should also not be maneuvered if trauma to any part of the body is evident. Moving the head toward the sides or pressing the bones on the neck will not help assess for neck rigidity correctly. While assessing for neck rigidity, sensation at the neck area is not to be assessed.

A client with lower back pain is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should prioritize what action? a. Positioning the client with the head of the bed elevated 45 degrees b. Administering IV morphine sulfate to prevent headache c. Limiting fluids for the next 12 hours d. Helping the client perform deep breathing and coughing exercises

a After myelography, the client lies in bed with the head of the bed elevated 30 to 45 degrees. The client is advised to remain in bed in the recommended position for 3 hours or as prescribed. Drinking liberal amounts of fluid for rehydration and replacement of CSF may decrease the incidence of post-lumbar puncture headache. Deep breathing and coughing exercises are not normally necessary since there is no consequent risk of atelectasis.

The nurse is preparing a child for a cisternal puncture to extract cerebrospinal fluid (CSF) for neurological diagnosis. To perform cisternal puncture, which of the following areas on the child's body should be shaved? a. The back of the neck b. The lateral aspect of the skull c. The lower abdomen d. The lower lumbar region

a The back of the neck is shaved because the needle is inserted just below the occipital bone of the skull. Cisternal puncture is very specific to this location and is not performed on any other part of the body.

A client is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this client, the nurse has the client stick out her tongue and move it back and forth. What is the nurse assessing? a. Function of the hypoglossal nerve b. Function of the vagus nerve c. Function of the spinal nerve d. Function of the trochlear nerve

a The hypoglossal nerve is the 12th cranial nerve. It is responsible for movement of the tongue. None of the other listed nerves affects motor function in the tongue.

Which cranial nerve is responsible for muscles that move the eye and lids? a. Oculomotor b. Trigeminal c. Vestibulocochlear d. Facial

a The oculomotor (III) cranial nerve is also responsible for pupillary constriction and lens accommodation. The trigeminal (V) cranial nerve is responsible for facial sensation, corneal reflex, and mastication. The vestibulocochlear (VIII) cranial nerve is responsible for hearing and equilibrium. The facial (VII) nerve is responsible for salivation, tearing, taste, and sensation in the ear.

Working hard to memorize the functions of the cranial nerves is a typical part of nursing school. Not only is it important to correlate the proper nerve number and name, but including the proper function makes this task quite a challenge! Which cranial nerves are enabling you to read this question? a. All options are correct. b. oculomotor c. abducens d. trochlear

a The oculomotor (III), abducens (VI) and trochlear (IV) nerves all work within the functional realm of the eyes. Don't forget the optic (II) nerve!

Which lobe of the brain is responsible for spatial relationships? a. Parietal b. Temporal c. Occipital d. Frontal

a The parietal lobe is essential to a person's awareness of body position in space, size and shape discrimination, and right-left orientation. The frontal lobe controls information storage or memory and motor function. The temporal lobe contains the auditory receptive area. The occipital lobe is responsible for visual interpretation.

To evaluate a client's cerebellar function, a nurse should ask: a. "Do you have any problems with balance?" b. "Do you have any difficulty speaking?" c. "Do you have any trouble swallowing food or fluids?" d. "Have you noticed any changes in your muscle strength?"

a To evaluate cerebellar function, the nurse should ask the client about problems with balance and coordination. The nurse asks about difficulty speaking or swallowing to assess the functions of cranial nerves IX, X, and XII. Questions about muscle strength help her evaluate the client's motor system.

The nurse is assessing the client's pupils following a sports injury. Which assessment findings indicate a neurologic concern? Select all that apply. a. unequal pupils b. quick pupil reaction c. pinpoint pupils d. absence of pupillary response e. pupil reacts to light

a, c, d Normal assessment findings include that the pupils are equal and reactive to light. Pupils that are unequal, pinpoint in nature, or fail to respond indicate neurologic impairment.

The nurse is caring for a post-lumbar puncture client who is experiencing an intense headache. If the physician chooses aggressive treatment, which nursing action is anticipated? a. hanging an intravenous solution b. drawing venous blood to perform a blood patch c. applying ice to the back of the neck d. offering caffeinated drinks

b Aggressive treatment would include performing a blood patch by instilling 20 to 30 ml of the client's venous blood into the epidural space to seal the leak of CSF fluid. Increasing fluid intake and instilling parenteral caffeine sodium benzoate are less aggressive treatments. Applying ice to the head is a conservative treatment.

A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-related changes that may influence the assessment results. Of what phenomenon should the nurse be aware? a. Hyperactive deep tendon reflexes b. Reduction in cerebral blood flow c. Increased cerebral metabolism d. Hypersensitivity to painful stimuli

b Reduction in cerebral blood flow (CBF) is a change that occurs in the normal aging process. Deep tendon reflexes can be decreased or, in some cases, absent. Cerebral metabolism decreases as the client advances in age. Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used.

The nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response? a. observing the reaction of pupils to light b. observing the client's response to painful stimulus c. using the Romberg test d. assessing the client's sensitivity to temperature, touch, and pain

b The nurse evaluates motor response in a comatose or unconscious client by administering a painful stimulus. This action helps determine if the client makes an appropriate response by reaching toward or withdrawing from the stimulus. The Romberg test is used to assess equilibrium in a noncomatose client. Pupils are examined for their reaction to light to assess sensitivity in the third cranial (oculomotor) nerve. Sensitivity to temperature, touch, and pain is a test to assess the sensory function of the client and not motor response.

The sympathetic and parasympathetic nervous systems have a direct effect on the circulatory system. Stimulation of the parasympathetic nervous system (PNS) causes which of the following? a. Blood vessels in the heart muscle to dilate b. Heartbeat to decrease c. Blood pressure to increase d. Blood vessels in the skeletal muscles to dilate

b The parasympathetic nervous system has a constricting effect on the blood vessels in the heart and skeletal muscles; the heartbeat and blood pressure will decrease.

A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain? a. III b. IV c. V d. VI

c The trigeminal nerve (cranial nerve V) innervates the forehead, cheeks, and jaw, so pain in the face elicited when brushing the teeth would most likely involve this nerve.

As part of a start-of-shift nursing assessment, the nurse is documenting a patient's neurological status according to the Glasgow Coma Scale (GCS). What responses will the nurse assess to determine the patient's GCS score? Select all that apply. a. Best sensory response b. Best judgment c. Best eye opening d. Best verbal response e. Best motor response

c, d, e The three domains of the GCS are best eye opening, best verbal response, and best motor response.

A client has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important postprocedure nursing intervention should be performed to ensure the client's maximum comfort? a. Administer antihistamines according to the physician's prescription b. Keep the room brightly lit and play soothing music in the background c. Help the client take a brisk walk around the testing area d. Encourage the client to drink liberal amounts of fluids

d The nurse should encourage the client to take liberal fluids and should inspect the injection site for swelling or hematoma. These measures help restore the volume of cerebrospinal fluid extracted. The client is administered antihistamines before a test only if he or she is allergic to contrast dye and contrast dye will be used. The room of the client who has undergone a lumbar puncture should be kept dark and quiet. The client should be encouraged to rest, because sensory stimulation tends to magnify discomfort.