chapter 65- assessment of neurologic function

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

"Do you have any problems with balance?"

A male client is scheduled for an electroencephalogram (EEG). When the nurse caring for the client is preparing him for the test, the client states that during childhood he was mildly electrocuted but miraculously lived. Therefore, he is quite afraid of going through an EEG. In what ways can the nurse help dispel the client's fear regarding the test? Distract the client's attention from the test. Inform the client that he will not experience any electrical shock. Inform the client that he will experience only mild electrical shock. Encourage adequate water intake by the client.

Inform the client that he will not experience any electrical shock.

Which of the following is an age-related change in the nervous system? Loss of neurons in the brain More efficient temperature regulation Increased myelin Increased cerebral blood flow

Loss of neurons in the brain

The nurse 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-

A patient is admitted to a specialty care unit with a diagnosis of an upper motor neuron lesion. The nurse assesses the patient and documents the presence of: Decreased muscle tone. Flaccid muscle paralysis. Muscle spasticity. Absent reflexes.

Muscle spasticity.

The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of cranial nerve: II VI VIII XI

VIII- vestibulocochlear or auditory nerve responsible for hearing and balance

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? VIII X III VII

X- vagus nerve and deals with gag reflex, laryngeal hoarseness, swallowing

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

ataxia- inability to coordinate voluntary muscle action; tremors (rhythmic, involuntary movements) noted at rest or during movement suggest a problem in the anatomic areas responsible for balance and coordination.

Lesions in the temporal lobe may result in which type of agnosia? Auditory Visual Tactile Relationship

auditory

he 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-are a parasympathetic effect

If a client has a lower motor neuron lesion, the nurse would expect the client to exhibit hyperactive reflexes. no muscle atrophy. muscle spasticity. decreased muscle tone.

decreased muscle tone-

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates: dysfunction in the cerebrum. risk for increased intracranial pressure. dysfunction in the brain stem. dysfunction in the spinal column.

dysfunction in the brain stem.

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

frontal

Which cranial nerve is responsible for muscles that move the eye and lids? Oculomotor Trigeminal Vestibulocochlear Facial

oculomotor- responsible for pupillary constriction and lens accommodation.

The physician's office 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? Myelogram Electroencephalogram Echoencephalography Cerebral angiography

Cerebral angiography-detects distortion of the cerebral arteries and veins

A 53-year-old man presents to the emergency department with a chief complaint of inability to form words, and numbness and weakness of the right arm and leg. Where would you locate the site of injury? Left frontoparietal region Right frontoparietal region Left basal ganglia Left temporal region

Left frontoparietal region-

What part of the brain controls and coordinates muscle movement?

Cerebellum

Which term describes the fibrous connective tissues that cover the brain and spinal cord? Meninges Dura mater Arachnoid mater Pia mater

meninges-The meninges have three layers: the dura mater, arachnoid mater, and pia mater

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

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

Which neurotransmitter demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways? Enkephalin Norepinephrine Acetylcholine Serotonin

serotonin-

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? 0 1+ 2+ 3+

1+

The nurse is assisting with a lumbar puncture and observes that when the physician obtains CSF, it is clear and colorless. What does this finding indicate? A subarachnoid hemorrhage An overwhelming infection A normal finding; the fluid will be sent for testing to determine other factors Local trauma from the insertion of the needle

A normal finding; the fluid will be sent for testing to determine other factors

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-iodine shell fish allergy

The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern? Physician maintains aseptic procedure. Cerebrospinal fluid is cloudy in nature. Client reports a piercing feeling. Client reports pressure relief in the head.

Cerebrospinal fluid is cloudy in nature-indication of infection

Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed? Ataxia Clonus Rigidity Flaccidity

Clonus-occurs when the foot is abruptly dorsiflexed. It continues to "beat" two or three times before it settles into a position of rest

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

Facial-controls facial expression and muscle movement, salivation and tearing, taste, and sensation in the ear.

Cranial nerve IX is also known as which of the following? Glossopharyngeal Vagus Spinal accessory Hypoglossal

Glossopharyngeal

A patient is having a lumbar puncture and the physician has removed 20 mL of cerebrospinal fluid. What nursing intervention is a priority after the procedure? Early ambulation Have the patient lie flat for 6 hours. Have the patient lie flat for 1 hour and then sit for 1 hour before ambulating. Have the patient lie in a semi-Fowler's position with the head of the bed at 30º.

Have the patient lie flat for 6 hours.

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure? Prone, with the head turned to the right Supine, with the knees raised toward the chest Lateral recumbent, with thighs flexed Lateral, with right leg flexed

Lateral recumbent, with thighs flexed- needle inserted between L4 and L5

A client presents to the emergency department status post-seizure. The physician wants to know what the pressure is in the client's head. What test might be ordered on this client? Lumbar puncture Echoencephalography Nerve conduction studies EMG

Lumbar puncture

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- trigenimal nerve- innervates forehead, cheeks, and jaw

Which cranial nerve is tested by listening to a ticking watch? Acoustic Facial Vagus Trigeminal

acoustic

A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects in the body systems, the nurse anticipates that the liver will: cease function and shunt blood to the heart and lungs. convert glycogen to glucose for immediate use. produce a toxic byproduct in relation to stress. maintain a basal rate of functioning.

convert glycogen to glucose for immediate use.

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

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- major functions of this lobe are concentration, abstract thought, information storage or memory, and motor function.

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

gag reflex-glossopharyngeal nerve IX

Which of the following areas of the brain are responsible for temperature regulation? Hypothalamus Thalamus Pons Medulla

hypothalamus- controls and regulates the autonomic nervous system and maintains temperature by promoting vasoconstriction or vasodilation

The pre-nursing class is learning about the nervous system in their anatomy class. What part of the nervous system would the students learn is responsible for digesting food and eliminating body waste? Central Sympathetic Peripheral Parasympathetic

parasympathetic-

Which lobe of the brain is responsible for spatial relationships? Parietal Temporal Occipital Frontal

parietal- essential to a person's awareness of body position in space, size and shape discrimination, and right-left orientation

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.

The nurse is caring for a client in the emergency department with a diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the client's face and torso. The nurse would provide further instruction after seeing that the nurse aide: used mild soapy water to clean the face. moved the client's head to clean behind the ears. cleaned the eye area from the inner to outer eye area. cleaned the neck and upper chest area.

moved the client's head to clean behind the ears-There should be no movement of the client's head when there is a history of head trauma

What safety actions does the nurse need to take 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 top of the MRI 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 is located.

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

A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position? Head of the bed elevated 45 degrees Prone Supine with feet raised Supine with the head lower than the trunk

Head of the bed elevated 45 degrees-to slow the upward dispersion of the dye

A client who has sustained a head injury to the parietal lobe cannot identify a familiar object by touch. The nurse knows that this deficit is which of the following? Visual agnosia Positive Romberg Ataxia Tactile agnosia

Tactile agnosia-inability to identify a familiar object by touch

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

Electromyography-obtained by inserting needle electrodes into skeletal muslces to measure changes in electrical potential of the muscles

A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture? Administer antihistamines to the client. Provide adequate caffeine-rich drinks to the client. Leave the client to rest and do not perform any assessments. Position the client flat for at least 3 hours.

Position the client flat for at least 3 hours-help restore CSF volume extracted from the client

he 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? Computed tomography Magnetic resonance imaging Transcranial Doppler Cerebral angiography

transcranial doppler- studies are used to study a tumor's blood flow within intracranial blood vessels. Cerebral angiography may be used to study a tumor's blood supply or obtain information about vascular lesions. Magnetic resonance imaging provides information similar to that provided by computed tomography, but with improved tissue contrast, resolution, and anatomic definition, and it examines the lesion in multiple planes.

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

VII- acoustic nerve, has to do with hearing, air and bone conduction, and balance

A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult slowing transmission of the motor neurons, the nurse would anticipate a delayed reaction in: identification of information due to slowed passages of information to brain. cognitive ability to understand relayed information. processing information transferred from the environment. response due to interrupted impulses from the central nervous system

response due to interrupted impulses from the central nervous system

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."

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-

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? observing the reaction of pupils to light observing the client's response to painful stimulus using the Romberg test assessing the client's sensitivity to temperature, touch, and pain

observing the client's response to painful stimulus

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term? Ataxic Dystrophic Helicopod Steppage

Helicopod-

What is the function of cerebrospinal fluid (CSF)? It cushions the brain and spinal cord. It acts as an insulator to maintain a constant spinal fluid temperature. It acts as a barrier to bacteria. It produces cerebral neurotransmitters.

It cushions the brain and spinal cord-It acts as a shock absorber and cushions the spinal cord and brain against injury caused by sudden or extreme movement. CSF also functions in the removal of waste products from cerebral tissue.

A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for: hypoxia. fever. visual disturbance. gait alteration.

hypoxia-Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing, and coughing