Chapter 36: Introduction to the Nervous System - ML5

A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first?

Assess the client for medication allergies.

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?

V

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." 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).

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."

What is the function of cerebrospinal fluid (CSF)?

-Shock Absorber -Carries nutrients -Carries wastes -Brain and Spinal Cord *moist* -Presence of some disorders -Transmit meds

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:

15

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?

7

Which of the following Glasgow Coma Scale scores indicates coma?

7

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:

Age-related changes to the neurological system

The nurse is caring for an 80-year-old client with a pre-existing history of dulled tactile sensation. The nurse should first consider what possible cause for this client's diminished tactile sensation?

Age-related neurologic changes

A client is scheduled for an EEG. The client asks about any diet-related prerequisites before the EEG. Which diet-related advice should the nurse provide to the client?

Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours before the test.

A client is scheduled for an EEG. The client inquires about any diet-related prerequisites before the EEG. Which diet-related advice should the nurse provide to the client?

Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours before the test.

A client is currently being stimulated by the parasympathetic nervous system. What effect will this nervous stimulation have on the client's bladder?

Bladder contract

The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve?

CN I

The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart?

CN II

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:

Cerebellum. Explanation: 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 nurse is assessing a client with hyperactive reflexes. When the client's foot is abruptly dorsiflexed, it continues to "beat" two to three times before settling into a resting position. How should the nurse document this finding?

Clonus

Which is a sympathetic effect of the nervous system?

Dilated pupils Explanation: Dilated pupils are a sympathetic effect of the nervous system, whereas constricted pupils are a parasympathetic effect. Decreased blood pressure is a parasympathetic effect, whereas increased blood pressure is a sympathetic effect. Increased peristalsis is a parasympathetic effect, but decreased peristalsis is a sympathetic effect. Decreased respiratory rate is a parasympathetic effect, and increased respiratory rate is a sympathetic effect.

A trauma client in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death?

Electroencephalography (EEG)

What safety actions does the nurse need to take for a client receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)?

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

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 Explanation: The frontal lobe, the largest lobe, located in the front of the brain. The major functions of this lobe are concentration, abstract thought, information storage or memory, and motor function. It contains Broca's area, which is located in the left hemisphere and is critical for motor control of speech. The frontal lobe is also responsible in large part for a person's affect, judgment, personality, and inhibitions (Hickey, 2009).

Cranial nerve IX is also known as which of the following?

Glossopharyngeal

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

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!

The nurse is caring for a client after lumbar puncture. The client reports a severe headache. Which actions should the nurse complete? Select all that apply.

Maintain the client on bed rest. Administer fluids to the client. Administer analgesic medication.

The nurse is caring for a post-lumbar puncture client experiencing an intense headache. The physician is notified and arriving to assess the client. If the physician chooses aggressive treatment, which nursing action is anticipated?

Maintain the client on bed rest. Administer fluids to the client. Position the client in the supine position. Administer analgesic medication.

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?

Occipital 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.

Which lobe of the brain is responsible for spatial relationships?

Parietal Explanation: 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.

Which cerebral lobe contains the auditory receptive areas?

Temporal Explanation: 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 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?

Variations in tissue density

Which term refers to the inability to coordinate muscle movements, resulting in difficulty walking?

ataxia

A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with:

body temperature control. Explanation: The body's thermostat is located in the hypothalamus; therefore, injury to that area can cause problems with body temperature control. Balance and equilibrium problems are related to cerebellar damage. Visual acuity problems would occur following occipital or optic nerve injury. Thinking and reasoning problems are the result of injury to the cerebrum

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

cranial nerve II

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

decerebrate

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?

decorticate

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

electromyography

Which of the following areas of the brain are responsible for temperature regulation?

hypothalamus

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:

not move or manipulate the client's head while assessing for bleeding or swelling.

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?

occipital

Which lobe of the brain is responsible for spatial relationships?

parietal

The nurse is assessing a client's level of consciousness. The nurse speaks the client's name, strokes the client's hand, and moves the client's shoulder. There is a delay, and then the client states, "What do you want?" before falling asleep again. Which level of conscious should the nurse document?

somnolent

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

The nurse is performing a neurologic assessment on a client diagnosed with a stroke and cannot elicit a gag reflex. This deficit is related to which of the following cranial nerves?

x