Chapter 36: Introduction to the Nervous System

A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following? "The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid." "The blood will replace the cerebral spinal fluid that has leaked out." "The blood can repair damage to the spinal cord that occurred with the procedure." "The blood provides moisture at the site, which encourages healing."

"The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid"

A patient who has been diagnosed with colon cancer is scheduled to undergo positron emission tomography (PET) to search for metastases. In preparation for this diagnostic procedure, what teaching point should the nurse provide to the patient? "Sound waves will be refracted throughout your body and a computer will analyze them." "A series of X-rays will be taken that will be combined to create a three-dimensional image your body." "It's very important that all metal objects be removed from your body before the test." "You'll be given a radioactive substance that will be measured during the test."

"You'll be given a radioactive substance that will be measured during the test."

A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with: body temperature control. balance and equilibrium. visual acuity. thinking and reasoning.

Body temperature control

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? cerebellum cerebrum brain stem midbrain

Cerebellum

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: first and second lumbar vertebrae. first and second cervical vertebrae. first and second thoracic vertebrae. fourth and fifth thoracic vertebrae.

First and second lumbar vertebrae

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? Frontal Occipital Temporal Parietal

Occipital

A patient is brought to the emergency room following a motor vehicle accident in which she sustained a head trauma. The patient is complaining of blindness in her left eye. The nurse would be correct in suspecting that this sensory deficit is related to damage in what cerebral lobe? Temporal Occipital Parietal Frontal

Occipital

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? Temporal lobe Parietal—occipital area Inferior-posterior frontal areas Posterior frontal area

Parietal-occipital area

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

When, if any, was your last narcotic use?

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? "It is a test for balance." "It is a test for coordination." "It is a test for muscle strength." "It is a test for motor ability."

"It is a test for balance."

Which of the following Glasgow Coma Scale scores indicates coma? 7 9 11 13

7

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? Trigeminal Acoustic Hypoglossal Trochlear

Acoustic

The nurse is completing a neurologic assessment and uses the whisper test to assess which cranial nerve? Vagus Acoustic Facial Olfactory

Acoustic

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

Assess the client for medication allergies.

Which term refers to the inability to coordinate muscle movements, resulting in difficulty walking? Agnosia Ataxia Spasticity Rigidity

Ataxia

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. Best sensory response Best judgment Best eye opening Best verbal response Best motor response

Best eye opening Best verbal response Best motor response

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

CN II

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? Cerebellar dysfunction A lesion in the pons Dysfunction of the medulla A hemorrhage in the midbrain

Cerebellar dysfunction

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? comatose somnolence stupor normal

Comatose

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

Constricted pupils

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

Cranial nerve II

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: cranial nerves I and II. cranial nerves III and V. cranial nerves VI and VIII. cranial nerves IX and X.

Cranial nerves IX and X Swallowing is a motor function of cranial nerves IX and X

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 normal. flaccid. decorticate. decerebrate.

Decerebrate

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities? Decerebrate Decorticate Flaccid Normal

Decorticate

A trauma client in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death? Magnetic resonance imaging (MRI) Electroencephalography (EEG) Electromyography (EMG) Computed tomography (CT)

Electroencephalography (EEG)

Which cerebral lobes is the largest and controls abstract thought? Temporal Frontal Parietal Occipital

Frontal

Which lobe of the brain is responsible for concentration and abstract thought? Frontal Parietal Temporal Occipital

Frontal

A patient sustained a head injury during a fall and has changes in personality and affect. What part of the brain does the nurse recognize has been affected in this injury? Frontal lobe Parietal lobe Occipital lobe Temporal lobe

Frontal lobe

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

Have the client identify familiar odors with the eyes closed.

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? Hot or cold packs Analgesics Anti-inflammatory medications Whirlpool baths

Hot or cold packs

A neurological nurse is conducting a focused neurological assessment of a patient who has just been admitted to the rehabilitative facility. During this assessment, the nurse has asked the patient to swallow and has tested the patient's gag reflex with a tongue depressor. These assessments test the function of which of the patient's cranial nerves? I (olfactory) and III (oculomotor) IV (trochlear) and V (trigeminal) VI (abducens) and VII (facial) IX (glossopharyngeal) and X (vagus)

IX (glossopharyngeal) and X (vagus)

In the course of a focused neurologic assessment, the nurse is palpating the client's major muscle groups at rest and during passive movement. Data gleaned from this assessment will allow the nurse to describe which of the following aspects of neurologic function? Muscle dexterity Muscle tone Motor symmetry Deep tendon reflexes

Muscle tone

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? Temporal Occipital Parietal Frontal

Occipital lobe

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? frontal parietal temporal occipital

Occipital lobe

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. Position the client flat for at least three hours or as directed by the physician. Encourage a liberal fluid intake for the client. Shampoo the client's hair with warm water. Keep the room brightly lit and play soothing music in the background.

Position the client flat for at least three hours or as directed by the physician Encourage a liberal fluid intake for the client

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis? Risk for aspiration Risk for falls Risk for impaired skin integrity Decreased intracranial adaptive capacity

Risk for aspiration

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? Risk for aspiration Risk for falls Risk for ineffective thermoregulation Risk for ineffective breathing pattern

Risk for falls

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: Speech. Vision. Hearing. Balance.

Speech

A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in thought content. motor ability. intellectual function. emotional status.

Thought content

A nurse is performing a neurologic assessment on the client and notes a positive Romberg test. This test for balance is related to which of the following cranial nerves? VIII X III VII

VIII

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? milligram electroencephalogram echoencephalography cerebral angiography

cerebral angiography

The nurse is admitting a client to the unit who is diagnosed with a lower motor neuron lesion. What entry in the client's electronic record is most consistent with this diagnosis? "Client exhibits increased muscle tone." "Client demonstrates normal muscle structure with no evidence of atrophy." "Client demonstrates hyperactive deep tendon reflexes." "Client demonstrates an absence of deep tendon reflexes."

"Client demonstrates an absence of deep tendon reflexes."

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

"Who is the president of the United States?"

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? Frontal lobe Occipital lobe Parietal lobe Brain stem

Brain stem

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? Premature degradation of acetylcholine Decreased availability of dopamine Insufficient synthesis of epinephrine Delayed reuptake of serotonin

Decreased availability of dopamine

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: Cranial nerve dysfunction An upper motor neuron lesion Age-related changes to the neurological system The development of a posterior spinal nerve lesion

Age-related changes to the neurologcial system

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? Damage to cranial nerve VIII Adverse medication effects Age-related neurologic changes An undiagnosed cerebrovascular disease in early adulthood

Age-related neurologic changes

Which is a sympathetic effect of the nervous system? Decreased blood pressure Increased peristalsis Dilated pupils Decreased respiratory rate

Dilated pupils

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? Administer antihistamines according to the physician's prescription Keep the room brightly lit and play soothing music in the background Help the client take a brisk walk around the testing area Encourage the client to drink liberal amounts of fluids

Encourage the client to drink liberal amounts of fluids

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? "I am trying to quit smoking and have a patch on." "I have been trying to get an appointment for so long." "I have not had anything to eat or drink since 3 hours ago." "My legs go numb sometimes when I sit too long."

"I am trying to quit smoking and have a patch on."

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)? Assess the client's vital signs and correlate these with the client's baselines. Assess the client's eye opening and response to stimuli. Document that the client currently lacks a level of consciousness. Facilitate diagnostic testing in an effort to obtain objective data.

Assess the client's eye opening and response to stimuli.

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? Withholding stimulants 24 to 48 hours prior to exam Removing all metal-containing objects Instructing the patient to void prior to the MRI Initiating an IV line for administration of contrast

Removing all metal-containing objects

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? "It's good to know the continual tingling in my fingers and toes is not connected with my nervous system!" "I need to be careful with my allergy to seafood!" "There are several types of tests to see what's causing the tingling in my fingers and toes." All of the comments indicate need for further client education.

"It's good to know the continua tingling in my fingers and toes is not connected with my nervous system!"

Which term refers to a method of recording, in graphic form, the electrical activity of a muscle? Electromyography Electroencephalography Electrocardiography Electrogastrography

Electromyography

When caring for a client with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would most likely elicit a response from cranial nerve VII? Palpate trapezius muscle while client shrugs shoulders against resistance. Administer the whisper or watch-tick test. Observe for facial movement symmetry, such as a smile. Note any hoarseness in the client's voice.

Observe for facial movement symmetry, such as a smile.

The nurse has completed evaluating the client's cranial nerves. The nurse documents impairment of the right cervical nerves (CN IX and CN X). Based on these findings, the nurse should instruct the client to refrain from eating or drinking for now. have their spouse bring in the client's glasses. wear any hearing aids while in the hospital. use the walker when walking.

Refrain from eating or drinking for now

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? "No metal objects can enter the procedure room." "You need to fast for 8 hours prior to the test." "You will need to lie still throughout the procedure." "There will be a lot of noise during the test."

"You will need to lie still throughout the procedure."

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: 20 15 10 5

15

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? Proximity to the CT scanner Variations in tissue density Metabolic activity Oxygen consumption

Variations in tissue density

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

Ensure that no client care equipment containing metal enters the room where the MRI table is located.

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? Cerebellum Thalamus Hypothalamus Midbrain

Hypothalamus

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? moving the head toward both sides lightly tapping the lower portion of the neck to detect sensation moving the head and chin toward the chest gently pressing the bones on the neck

Moving the head and chin toward the chest

What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brain's surface? Dura mater Arachnoid Fascia Pia mater

Pia mater

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? Positioning the client with the head of the bed elevated 45 degrees Administering IV morphine sulfate to prevent headache Limiting fluids for the next 12 hours Helping the client perform deep breathing and coughing exercises

Positioning the client with the head of the bed elevated 45 degrees

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? III IV V VI

V