Hesi EAQ Neurologic and Sensory Systems

What is the maximum amount of time the nurse should allow an older adult with a cerebrovascular accident (also known as "brain attack") to remain in one position? 1 1 to 2 hours 2 3 to 4 hours 3 15 to 20 minutes 4 30 to 40 minutes

1 to 2 hours Change of position at least every 1 or 2 hours helps prevent the respiratory, urinary, and cutaneous complications of immobility [1] [2]. Too protracted a period of time in one position, such as every 3 to 4 hours, increases the potential for respiratory, urinary, and neuromuscular impairment; prolonged physical pressure increases the possibility of skin breakdown. Fifteen to 20 minutes and 30 to 40 minutes are unnecessarily short time intervals; too frequent repositioning may interfere with the client's rest. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.

Which type of client eye disorders are caused by Staphylococcus aureus? Select all that apply. 1 Ectropion 2 Trachoma 3 Hordeolum 4 Conjunctivitis 5 Chalazion

3 Hordeolum 4 Conjunctivitis A hordeolum is an infection of the eyelid sweat gland caused by Staphylococcus aureus and Staphylococcus epidermidis. Bacterial conjunctivitis is most often caused by S. aureus. An ectropion is the turning outward and sagging of the eyelid, caused by muscle relaxation or weakness. Trachoma is a chronic conjunctivitis caused by caused by Chlamydia trachomatis. Chalazion is an inflammation of a sebaceous gland in the eyelid.

Immediately after cataract surgery a client reports feeling nauseated. What should the nurse do? 1 Provide some dry crackers to eat 2 Administer the prescribed antiemetic 3 Explain that this is expected after surgery 4 Encourage deep breathing until the nausea subsides

Administer the prescribed antiemetic An antiemetic will prevent vomiting; vomiting increases intraocular pressure and should be avoided. Aggressive intervention is required rather than dry crackers. Explaining that this is expected after surgery is incorrect. Deep breathing will not minimize nausea; aggressive intervention is required to prevent vomiting.

A client is going for a magnetic resonance imaging (MRI). What should the nurse ascertain before taking the client to the procedure? 1 Scheduled medications have been given. 2 All metal, such as jewelry and hair ornaments, has been removed. 3 Adequate prehydration has been given. 4 The client has emptied the bladder.

All metal, such as jewelry and hair ornaments, has been removed. All metal must be removed because the MRI emits a strong magnetic field. All medications may not be necessary before the test. Prehydration is not necessary and may cause interruptions for client to void. The client should have the opportunity to void before going for the test.

A client asks for information about glaucoma. How should the nurse explain glaucoma to the client? 1 An increase in the pressure within the eyeball 2 An opacity of the crystalline lens or its capsule 3 A curvature of the cornea that becomes unequal 4 A separation of the neural retina from the pigmented retina

An increase in the pressure within the eyeball

The spouse of a client who had a cerebrovascular accident (also known as a "brain attack") seems unable to accept the concept that the client must be encouraged to participate in self-care. What is the best response by the nurse? 1 Tell the spouse to let the client do things independently. 2 Allow the spouse to assume total responsibility for the client's care. 3 Explain that the nursing staff has full responsibility for the client's activities. 4 Ask the spouse for assistance in planning those activities most helpful to the client.

Ask the spouse for assistance in planning those activities most helpful to the client. To foster communication and cooperation, family members should be involved in planning and implementing care. Telling the spouse to let the client do things independently does not focus on feelings or needs. The spouse may promote dependency in the client to satisfy a need to control. Although the nursing staff does have full responsibility for the client's activities, the family should be involved.

A client is scheduled for head and neck surgery. Although the healthcare provider has explained the surgery, the client still has moderate to severe anxiety. Which action should the nurse take initially? 1 Attempt to discover what the client is concerned about. 2 Elaborate on what the healthcare provider has already said. 3 Teach the client to use the suction equipment preoperatively. 4 Plan for postoperative communication because a tracheostomy is likely.

Attempt to discover what the client is concerned about. Various aspects of hospitalization and diagnosis may cause the client to become anxious. The nurse should identify what concerns the client the most. Anxiety interferes with learning, and it is the healthcare provider's responsibility to explain the surgery. Teaching the client to use the suction equipment preoperatively may cause the client unnecessary anxiety. A tracheostomy may not be performed; it depends on the type of surgery.

A nurse uses a dull object to stroke the lateral side of the underside of a client's left foot and moves upward to the great toe. What reflex is the nurse testing? 1 Moro 2 Babinski 3 Stepping 4 Cremasteric

Babinski This is the description of how to elicit the Babinski reflex. If it is present in adults it may indicate a lesion of the pyramidal tract. The Babinski reflex is expected in newborns and disappears after one year. The Moro (startle) reflex is expected in newborns. It disappears between the third and fourth months; if present after four months, neurologic disease is suspected. The stepping reflex is expected in newborns. It disappears at about three to four weeks after birth and is replaced by more deliberate action. The cremasteric is a superficial reflex that tests lumbar segments 1 and 2. Stimulation of this reflex is useful in initiating reflex emptying of the spastic bladder after a spinal cord disruption above the second, third, or fourth sacral segment.

A client has inflammation of the facial nerve, causing facial paralysis on one side. Which diagnosis will the nurse most likely observe written in the medical record? 1 Botulism 2 Bell palsy 3 Trigeminal neuralgia 4 Guillain-Barré syndrome

Bell palsy Bell palsy is a cranial nerve disorder characterized by inflammation of the facial nerve on one side of the face. Botulism is a type of polyneuropathy caused by food poisoning due to Clostridium botulinum that can be fatal. Trigeminal neuralgia is a cranial nerve disorder characterized by pain in the distribution of the trigeminal nerve. Guillain-Barré syndrome is an acute, rapidly progressing, potentially fatal polyneuritis.

Which beta-adrenergic blocker is prescribed to clients with glaucoma? 1 Betaxolol 2 Carbachol 3 Brimonidine 4 Methazolamide

Betaxolol Betaxolol is a beta-adrenergic blocker that is prescribed for glaucoma. Carbachol is a cholinergic agent that is used to treat glaucoma. Brimonidine is an alpha-adrenergic agonist that is prescribed in glaucoma. Methazolamide is a carbonic anhydrase inhibitor that is used to treat glaucoma.

Which anatomical area in the brain regulates a client's verbal expression? 1 Broca's area 2 Wernicke's area 3 Association area 4 Supplemental area

Broca's area Broca's area in the cerebrum regulates verbal expression. Wernicke's area integrates auditory language. Association areas have many functions like sensory input, integration of visual and auditory inputs, past experiences, judgment, and reasoning. Supplemental areas facilitate proximal muscle activity.

Which structure lies inside and parallel to the sclera? 1 Lens 2 Choroid 3 Conjunctiva 4 Ciliary processes

Choroid The choroid is a highly vascular structure that nourishes the ciliary body, the iris, and the outermost portion of the retina. It lies parallel to the sclera. The lens is located behind the iris. The conjunctiva covers the inner surfaces of the eyelids and also extends over the sclera. The ciliary processes lie behind the peripheral part of the iris.

Which radiologic study is used to obtain radiographic images of the client's brain for three-dimensional intracranial contents? 1 Electromyography 2 Cerebral angiography 3 Computed tomography (CT) 4 Transcranial doppler

Computed tomography (CT) A computed tomography (CT) scan provides a rapid means of obtaining radiographic images of the brain to provide a three-dimensional representation of the intracranial contents. Electromyography is used to record electrical activity associated with innervations of skeletal muscle. Cerebral angiography is used to view vascular lesions or tumors. Transcranial doppler evaluates blood flow velocities of the intracranial blood vessels.

Which part of the brain contains the client's "central switchboard" of the central nervous system? 1 Cerebrum 2 Brain stem 3 Cerebellum 4 Diencephalon

Diencephalon The thalamus is considered to be the major relay station or "central switchboard" for the central nervous system (CNS). The thalamus, along with the hypothalamus and epithalamus, are located in the diencephalon of the brain. The cerebrum is the largest part of the brain, which has right and left lateral ventricles deep inside and has basal ganglia at its base. The brainstem connects the rest of the brain with the CNS. It is associated with life support and basic functions, such as movement. The cerebellum is concerned with coordination of movement and works together with the brainstem to focus on the functionality of the muscles. This structure is found below the occipital lobe and adjacent to the brainstem.

A registered nurse assesses a client's electronic medical record (EMR) and observes increased blood pressure, severe myopia, and blood glucose levels. Which type of eye disorder will the nurse most likely observe written in the EMR? 1 Cataract 2 Glaucoma 3 Corneal abrasions 4 Keratoconjunctivitis sicca

Glaucoma

What is the function of limbic system? 1 Influence emotional behavior 2 Regulate autonomic functions 3 Facilitate automatic movements Incorrect 4 Relay sensory and motor inputs for cerebrum

Influence emotional behavior Located lateral to the hypothalamus, the limbic system influences emotional behavior and basic drives such as feeding and sexual behaviors. The regulation of endocrine and autonomic functions is the function of the hypothalamus. The control and facilitation of learned and automatic movements is the function of the basal ganglia. The thalamus relays sensory and motor input to and from the cerebrum

An adult client is brought to the emergency department by a friend who states, "We were all partying at a club, and all of a sudden my friend collapsed." Vital signs revealed a temperature of 99.2° F, pulse of 152, respiratory rate of 32, blood pressure of 163/92. After performing a physical assessment and collecting a health history from the client, what action should the nurse take next? 1 Reassess the client and allow the friend to stay. 2 Inform the healthcare provider of the client's status and prepare to start an intravenous (IV) line. 3 Assign the client to a private room and put a cool cloth on the client's forehead. 4 Place the client in a dimly lit room and perform a neurologic assessment every 15 minutes.

Inform the healthcare provider of the client's status and prepare to start an intravenous (IV) line. 4-methylenedioxy-methamphetamine (Ecstasy) is a drug of abuse that has both stimulant and hallucinogenic properties. Stimulants have the ability to cause dehydration by increasing activity and diaphoresis via increased adrenalin release. The client is displaying symptoms of dehydration; the healthcare provider must be informed so an IV can be prescribed. Letting the friend stay and reassessing the client in one hour are inappropriate; the client's vital signs indicate the need for immediate attention. Placing the client in a private room with a cool cloth on the head is inappropriate; the client's vital signs are indicative of a problem. Performing a neurologic assessment every 15 minutes is inappropriate at this time. The client's vital signs indicate a need for immediate medical attention. Test-Taking Tip: Avoid choosing answers that use words such as always, never, must, all, and none. If you are confused about the question, read the choices, label them true or false, and choose the answer that is the odd one out (i.e., the one false one or the one true one). When a question is framed in the negative, such as "When assessing for pain, you should not," the false option is the correct choice.

Which condition is characterized with an involuntary and rapid twitching of the client's eyeball? 1 Ptosis 2 Anisocoria 3 Nystagmus 4 Enophthalmos

Nystagmus Nystagmus is characterized by an involuntary and rapid twitching of the eyeball. Ptosis is characterized by drooping of eyelids. Anisocoria is characterized by a normally noticeable difference in the size of the pupils and is a normal finding in 5% of the population. Enophthalmos is characterized by the sunken appearance of the eye.

Which clinical indicator does the nurse expect to identify when assessing a client admitted with a herniated lumbar disk? 1 Pain radiating to the hip and leg 2 Stiffness in shoulders 3 Paralysis of both lower extremities 4 Overgrowth of tissue on the lower back

Pain radiating to the hip and leg Because of pressure on the sciatic nerve, pain radiating to the hip and leg is common. Although weakness (paresis) may occur, paralysis is not common. Shoulder stiffness and overgrowth of tissue on the lower back are not associated with this disorder.

Which action is the least likely to prevent sleep disturbances? 1 Avoiding reading, writing, and eating in bed 2 Getting out of bed if unable to fall sleep after 20 minutes 3 Performing strenuous exercise within an hour before going to bed 4 Lowering the temperature of the bedroom and keeping it dark and quiet

Performing strenuous exercise within an hour before going to bed To prevent sleep disturbances, a client should not perform strenuous exercise within six hours before bedtime. A client should avoid reading, writing, and eating in bed. To prevent sleep disturbances, a client should get out of bed if he or she is not able to fall sleep after 20 minutes. The client should also lower the temperature of the bedroom and keep it dark and quiet.

A client has sensorineural hearing loss. Which finding in the client's history will alert the nurse to the most likely cause of the sensorineural hearing loss? 1 Prolonged exposure to noise 2 Buildup of cerumen in the ear 3 Blockage of the ear from a foreign body 4 Perforation of the tympanic membrane

Prolonged exposure to noise Sensorineural hearing loss occurs due to damage to the auditory nerve in the inner ear. Prolonged exposure to noise can cause damage to the cochlea. Cerumen in the ear can cause obstruction in the ear and lead to a conductive hearing loss. Foreign bodies can cause infection and inflammation in the ear, thereby leading to a conductive hearing loss. Perforation of the tympanic membrane leads to an increased risk of ear infections, which can cause conductive hearing loss.

A client sustains a crushing injury of the spinal cord above the level of origin of the phrenic nerve. As a result of this injury, the nurse expects what client response? 1 Ventricular fibrillation 2 Dysfunction of the vagus nerve 3 Retention of sensation but paralysis of the lower extremities 4 Respiratory paralysis and cessation of diaphragmatic contractions

Respiratory paralysis and cessation of diaphragmatic contractions The phrenic nerve innervates the diaphragm. Therefore, a crushing spinal cord injury above the cervical plexuses, the level of phrenic nerve origin, results in respiratory paralysis. Cardiac activity will not be affected; the heart is regulated by the autonomic nervous system fibers originating in the medulla. Activities regulated by the vagus nerve will be unaffected; it originates in the medulla, which is superior to the cervical region; the phrenic nerves originate from the cervical plexuses. In a crushing spinal cord injury, both motor and sensory conduction are affected.

While setting up a client's food tray, the nurse identifies tremoring of the hand when it lies in the client's lap. The tremor disappears when the client reaches for silverware. What type of tremor should the nurse document in the client's medical record? 1 Resting tremor 2 Intention tremor 3 Voluntary tremor 4 Idiopathic tremor

Resting tremor A resting tremor (nonintention tremor) typically is present when the hand is not involved in a purposeful activity. The tremor is caused by decreased neurotransmitters. An intention tremor is exhibited or intensified when purposeful movements are attempted. The word voluntary implies that the tremor is under the client's control, which is not true. The cause of the disease may be idiopathic, but the type of the tremor is known as a resting or nonintention tremor.

A client is admitted with a brain attack (cerebrovascular accident, CVA) with left-sided paralysis. The client leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field. What should the client's plan of care include? 1 Approaching the client from the left side 2 Keeping the client's head turned to the right 3 Teaching the client to use head movements to scan the left field of vision 4 Arranging the furniture in the client's room so that the door is in the right visual field

Teaching the client to use head movements to scan the left field of vision The client should be encouraged to make a conscious attempt to turn the head to the left so that the remaining vision can be used to scan the environment and to compensate for the vision lost in the left visual field. The client should be approached from the right side because the left visual field is impaired. Keeping the head turned to the right increases the amount of the environment that cannot be seen in the left visual field; the head should be turned to the left. Although it may help to arrange furniture so that the door is in the client's right visual field, it is inadequate for safety; the client must be taught to scan the left visual field by turning the head to the left.

Which beta-adrenergic blocker is used to reduce a client's intraocular pressure? 1 Timolol 2 Travopost 3 Carbachol 4 Apraclonidine

Timolol Glaucoma is manifested by increased intraocular pressure. Timolol is a beta-adrenergic blocker used in the treatment of glaucoma. Carbachol is a cholinergic agonist used to treat glaucoma. Travopost is a prostaglandin agonist, and apraclonidine is an adrenergic agonist used in the treatment of glaucoma.

Which test helps a primary healthcare provider distinguish between conductive and sensorineural hearing loss? 1 Whisper test 2 Weber test 3 Tympanometry 4 Electrocochleography

Weber test