Chapter 60 (chapter questions)

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?"

Which cranial nerve is responsible for facial sensation and corneal reflex?

Trigeminal

If a client has a lower motor neuron lesion, the nurse would expect the client to exhibit

decreased muscle tone.

Lower motor neuron lesions cause

flaccid muscles.

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

Acoustic

Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed?

Clonus

If a client has a lower motor neuron lesion, the nurse would expect to observe which manifestation upon physical assessment?

Decreased muscle tone

Which is a sympathetic effect of the nervous system?

Dilated pupils

Which cranial nerve is responsible for muscles that move the eye and lids?

Oculomotor

The nurse is completing a neurological assessment and uses the whisper test to assess which cranial nerve?

Acoustic (VIII)

Which structural and motor change is related to aging and may be assessed in geriatric clients during an examination of neurological function?

Decreased or absent deep tendon reflexes

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.

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

Ataxia

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

Ataxia

Lesions in the temporal lobe may result in which type of agnosia?

Auditory

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

Electromyography

Which neurotransmitter inhibits pain transmission?

Enkephalin

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

Which safety action will the nurse implement 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 table is located.

The trochlear nerve controls which function?

Eye muscle movement

Which anatomic part supplies cerebrospinal fluid to the subarachnoid space and down the spinal cord on the dorsal surface?

Fourth ventricle

Which cerebral lobes is the largest and controls abstract thought?

Frontal

Which finding is considered a positive finding of the Romberg test?

Loss of balance

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. Position the client in the supine position. Prepare for an epidural blood patch. Administer analgesic medication. Administer fluids to the client.

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

Which term describes the fibrous connective tissues that cover the brain and spinal cord?

Meninges

Which lobe of the brain is responsible for spatial relationships?

Parietal

Which cerebral lobe contains the auditory receptive areas?

Temporal

The nurse is preparing the client for a diagnostic test to evaluate blood flow within intracranial blood vessels. For which test is the nurse preparing the client?

Transcranial Doppler

Which diagnostic test may be performed to evaluate blood flow within intracranial blood vessels?

Transcranial Doppler

A client is scheduled for standard EEG testing to evaluate a possible seizure disorder. Which nursing intervention should the nurse perform before the procedure?

Withhold anticonvulsant medications for 24 to 48 hours before the exam

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.

A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in

thought content.

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?

Encourage the client to drink liberal amounts of fluids

A nurse conducts the Romberg test by asking the client to stand with the feet close together and the eyes closed. As a result of this posture, the client suddenly sways to one side and is about to fall when the nurse intervenes and prevents the client from being injured. In which way should the nurse interpret the client's result?

Positive Romberg test, indicating a problem with equilibrium

Which neurotransmitter demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways?

Serotonin