Med Surg 1 Ch 60 Neuro Functions

A client preparing to undergo a lumbar puncture states he doesn't think he will be able to get comfortable with his knees drawn up to his abdomen and his chin touching his chest. He asks if he can lie on his left side. Which statement is the best response by the nurse?

"Although the required position may not be comfortable, it will make the procedure safer and easier to perform." The nurse should explain that the knee-chest position is necessary to make the procedure safer and easier to perform. Lying on his left side won't make the procedure easy or safe to perform. The nurse shouldn't simply tell the client there is no other option because the client is entitled to understand the rationale for the required position. Reporting the client's concerns to the physician won't meet the client's needs in this situation.

Which of the following neurotransmitters are deficient in myasthenia gravis?

Acetylcholine A decrease in the amount of acetylcholine causes myasthenia gravis. A decrease of serotonin leads to depression. Parkinson's disease is caused by a depletion of dopamine. Decreased levels of GABA may cause seizures.

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

Auditory Lesions in the temporal lobe (lateral and superior portions) may result in auditory agnosia. Lesions in the occipital lobe may result in visual agnosia. Lesions in the parietal lobe may result in tactile agnosia. Lesions in the parietal lobe (posteroinferior regions) may result in relationship and body part agnosia.

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

Glossopharyngeal Cranial nerve IX is the glossopharyngeal nerve. The vagus nerve is cranial nerve X. Cranial nerve XII is the hypoglossal nerve. The spinal accessory is the cranial nerve XI.

The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse should respond by describing the action of the:

sympathetic nervous system. The division of the autonomic nervous system called the sympathetic nervous system regulates the expenditure of energy. The neurotransmitters of the sympathetic nervous system are called catecholamines. During an emergency situation or an intensely stressful event, the body adjusts to deliver blood flow and oxygen to the brain, muscles, and lungs that need to react in the situation. The musculoskeletal system benefits from the sympathetic nervous system as the fight-or-flight effects pump blood to the muscles. The parasympathetic nervous system works to conserve body energy not expend it during an emergency. The endocrine system regulates metabolic processes.

To evaluate a client's cerebellar function, a nurse should ask:

"Do you have any problems with balance?" To evaluate cerebellar function, the nurse should ask the client about problems with balance and coordination. The nurse asks about difficulty speaking or swallowing to assess the functions of cranial nerves IX, X, and XII. Questions about muscle strength help her evaluate the client's motor system.

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." The Romberg test screens for balance. The client stands with feet together and arms at the side, first with eyes open and then with both eyes closed for 20 to 30 seconds. Slight swaying is normal, but a loss of balance is abnormal and is considered a positive Romberg test.

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

Acoustic Clinical examination of the acoustic nerve can be done by the whisper test. Having the client say "ah" tests the vagus nerve. Observing for symmetry when the client performs facial movements tests the facial nerve. The olfactory nerve is tested by having the client identify specific odors.

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

Ataxia Ataxia is the 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. Agnosia is the loss of ability to recognize objects through a particular sensory system. Spasticity is the sustained increase in tension of a muscle when it is passively lengthened or stretched.

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 Cranial nerve (CN) I is the olfactory nerve, which allows the sense of smell. Testing of CN I is done by having the patient identify familiar odors with eyes closed, testing each nostril separately. An inability to smell an odor is a significant finding, indicating dysfunction of this nerve.

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 The nurse assesses vision and thus the optic nerve (cranial nerve II) by use of a Snellen eye chart.

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. 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.

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?

Cerebral angiography The nurse would anticipate a cerebral angiography, which detects distortion of the cerebral arteries and veins . A myelogram detects abnormalities of the spinal canal. An electroencephalogram records electrical impulses of the brain. An echoencephalography is an ultrasound of the structures of the brain.

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, what does the nurse anticipate the liver will do?

Convert glycogen to glucose for immediate use. When the body is under stress, the sympathetic nervous system is activated readying the body for action. The effect of the body is to mobilize stored glycogen to glucose to provide additional energy for body action.

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

Decreased muscle tone A client with a lower motor neuron lesion would be expected to have decreased muscle tone. Those with upper motor neuron lesion would have hyperactive reflexes, no muscle atrophy, and muscle spasticity.

Which is a sympathetic effect of the nervous system?

Dilated pupils 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 patient is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the patient has?

Dysfunction of the vagus nerve The vagus nerve (cranial nerve X) controls the gag reflex and is tested by depressing the posterior tongue with a tongue blade. An absent gag reflex is a significant finding, indicating dysfunction of this nerve.

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. For client safety the nurse must make sure no client care equipment that contains metal or metal parts (e.g., portable oxygen tanks) enters the room where the MRI is located. The magnetic field generated by the unit is so strong that any metal-containing items will be strongly attracted and can literally be pulled away with such great force that they can fly like projectiles toward the magnet.

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 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).

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?

Lateral recumbent, with thighs flexed To maximize the space between the vertebrae, the client is placed in a lateral recumbent position with the thighs flexed toward the chin as much as possible. The needle is inserted between L4 and L5. The positions in the other answer choices would not allow as much space between L4 and L5.

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

Oculomotor The oculomotor (III) cranial nerve is also responsible for pupillary constriction and lens accommodation. The trigeminal (V) cranial nerve is responsible for facial sensation, corneal reflex, and mastication. The vestibulocochlear (VIII) cranial nerve is responsible for hearing and equilibrium. The facial (VII) nerve is responsible for salivation, tearing, taste, and sensation in the ear.

A nurse is caring for a client with slight expressive aphasia. Which nursing technique(s) facilitates communication with the client? Select all that apply.

Offer a communication board. Allow time for the client to respond to questions. Guess words the client has difficulty saying and confirm understanding with the client. The nurse should offer a communication board to the client, allow time for the client to respond to questions, and guess words the client has difficulty saying and confirm understanding with the client. Encouraging exercises such as whistling are appropriate for a client with dysarthria, not expressive aphasia. Providing sensory aids such as glasses is a technique appropriate for a client with receptive aphasia, not expressive aphasia.

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?

Parasympathetic The parasympathetic division of the autonomic nervous system works to conserve body energy and is partly responsible for slowing heart rate, digesting food, and eliminating body wastes.

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 that is slowing transmission of the motor neurons, in what would the nurse anticipate a delayed reaction?

Response due to interrupted impulses from the central nervous system The central nervous system is composed of the brain and the spinal cord. Motor neurons transmit impulses from the central nervous system. Slowing transmission in this area would slow the response of transmission leading to a delay in reaction. Sensory neurons transmit impulses from the environment to the central nervous system, allowing identification of a stimulus. Cognitive centers of the brain interpret the information.

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 motor strip, which lies in the frontal lobe, anterior to the central sulcus, is responsible for muscle movement. It also contains Broca's area (left frontal lobe region in most people), critical for motor control of speech.

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?

Tactile agnosia Tactile agnosia is the inability to identify a familiar object by touch. Visual agnosia is the loss of ability to recognize objects through sight. The Romberg test has to do with balance. Ataxia is defined as incoordination of voluntary muscle action.

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

Trigeminal The trigeminal (V) cranial nerve is also responsible for mastication. The oculomotor (III) cranial nerve is responsible for the muscles that move the eye and lid, pupillary constriction, and lens accommodation. The vestibulocochlear (VII) cranial nerve is responsible for hearing and equilibrium. The facial nerve is responsible for salivation, tearing, taste, and sensation in the ear.

The spinal cord is composed of 31 pairs of spinal nerves. How many pairs of thoracic nerves are contained within the spinal column?

Twelve There are twelve pairs of thoracic nerves, five lumbar and sacral nerves, eight cervical, and one coccygeal.

The provider orders the Romberg test for a patient. The nurse tells the patient that the provider wants to evaluate his equilibrium by assessing which cranial nerve?

VIII Cranial nerve VIII (acoustic) can be checked to assess equilibrium status.

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?

occipital The vision center is located in the occipital lobe. There is little that may interfere with the visual process in the other lobes of the brain.

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

thought content. Hallucinations are disturbances of thought content. They are not disturbances in motor ability, intellectual function, or emotional status.

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).

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?" Assessing orientation to time, place, and person assists in evaluating mental status. Does the client know what day it is, what year it is, and the name of the president of the United States? Is the client aware of where he or she is? Is the client aware of who the examiner is and why he or she is in the room? "Can you write your name on this piece of paper?" will assess language ability. "Can you count backward from 100?" assesses the client's intellectual function. "Are you having hallucinations?" assesses the client's thought content.

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. If a contrast agent is used, the client must be assessed before the CT scan for an iodine/shellfish allergy, because the contrast agent used may be iodine based. If the client has no allergies to iodine, then kidney function must also be evaluated, as the contrast material is cleared through the kidneys. A suitable IV line for contrast injection and a period of fasting (usually 4 hours) are required before the study. Clients who receive an IV contrast agent are monitored during and after the procedure for allergic reactions and changes in kidney function.

A nurse is working in a neurologist's office. The physician orders a Romberg test. What should the nurse instruct the client to do?

Close eyes and stand erect. In the Romberg test, the client stands erect with the feet close together and eyes closed. If the client sways as if to fall, it is considered a positive Romberg test. All of the other options include components of neurologic tests, indicating neurologic deficits and balance.

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 The nurse should encourage the client to take liberal fluids and should inspect the injection site for swelling or hematoma. These measures help restore the volume of cerebrospinal fluid extracted. The client is administered antihistamines before a test only if he or she is allergic to contrast dye and contrast dye will be used. The room of the client who has undergone a lumbar puncture should be kept dark and quiet. The client should be encouraged to rest, because sensory stimulation tends to magnify discomfort.

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. For client safety the nurse must make sure that no client care equipment that contains metal or metal parts (e.g., portable oxygen tanks) enters the room where the MRI is located. The client must be assessed for the presence of medication patches with foil backing (e.g., nicotine patch) that may cause a burn. The magnetic field generated by the unit is so strong that any metal-containing items will be strongly attracted and can literally be pulled away with such great force that they can fly like projectiles toward the magnet.

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?

Inform the client that he will not experience any electrical shock. An EEG records the electrical impulses generated by the brain. To prepare the client for the test, the nurse informs the client that he or she will not experience any electrical shock. The source of electrical energy is the client's neural activity within the brain and not any external electrical energy. Ensuring adequate water intake or distracting the attention of the client will not comfort the client about the technical nature of the test.

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. Position the client in the supine position. Administer analgesic medication. When the client assumes an upright position, tension and stretching of the venous sinuses and pain-sensitive structures occur. A postpuncture headache is usually managed by bed rest in a supine position, analgesic agents, and hydration.

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

Serotonin The brain stem, hypothalamus, and dorsal horn of the spinal cord are sources of serotonin. Enkephalin is excitatory and associated with pleasurable sensations. Norepinephrine is usually excitatory and affects mood and overall activity. Acetylcholine is usually excitatory, but the parasympathetic effects are sometimes inhibitory.

The nurse assists the health care provider (HCP) in completing a lumbar puncture (LP). Which should the nurse note as a concern?

The cerebrospinal fluid (CSF) is cloudy in nature. The CSF is normally clear and colorless; therefore, CSF that is cloudy would be noted by the nurse as a concern. The HCP is correct to maintain aseptic procedure. At 90 mm H20, the client's CSF fluid pressure falls within normal limits (between 80 and 100 mm H20). Sometimes the HCP will administer medication via intrathecal injection during an LP, which should not be a cause for concern.

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 brain stem. Decerebrate posturing indicates damage of the upper brain stem. Decorticate posturing indicates cerebral dysfunction. Increased intracranial pressure is a cause of decortication and decerebration. Alterations in sensation or paralysis indicate dysfunction in the spinal column.

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?

Brain stem The brain stem consists of the midbrain, pons, and medulla oblongata (see Fig. 65-2). Portions of the pons help regulate respiration. Motor fibers from the brain to the spinal cord and sensory fibers from the spinal cord to the brain are located in the medulla. Reflex centers for respiration, blood pressure, heart rate, coughing, vomiting, swallowing, and sneezing are located in the medulla.

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

Frontal The major functions of the frontal lobe are concentration, abstract thought, information storage or memory, and motor function. The parietal lobe analyzes sensory information such as pressure, vibration, pain, and temperature. The occipital lobe is the primary visual cortex. The temporal lobe contains the auditory receptive areas located around the temples.

Which cerebral lobe contains the auditory receptive areas?

Temporal 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.

The nurse is performing a neurological assessment of a client who has sustained damage to the frontal cortex. Which of the following deficits will the nurse look for during assessment?

The inability to tell how a mouse and a cat are alike The client with damage to the frontal cortex will display a deficit in intellectual functioning. Questions designed to assess this capacity might include the ability to recognize similarities: for example, how are a mouse and dog or pen and pencil alike? The Romberg test assesses balance, which has to do with the cerebellar and basal ganglia influence on the motor system. Absence of movement below the waist suggests a deficit with the spinal cord. Intentional tremors have to do with deficits of the motor system.

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 which cranial nerve?

VIII There are 12 pairs of cranial nerves. Cranial nerve VIII is the vestibulocochlear or auditory nerve responsible for hearing and balance. Cranial nerve II is the optic nerve. Cranial nerve VI is the abducens nerve responsible for eye movement. Cranial nerve XI is the accessory nerve and is involved with head and shoulder movement.

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 CN X is the vagus nerve and has to do with the gag reflex, laryngeal hoarseness, swallowing ability, and the symmetrical rise of the uvula and soft palate. CN VII is the facial nerve and has to do with symmetry of facial movements and the ability to discriminate between the tastes of sugar and salt. The inability to close one eyelid indicates impairment of this nerve. CN VIII is the acoustic nerve. It has to do with hearing, air and bone conduction, and balance. CN III is the oculomotor nerve and has to do with pupillary response, conjugate movements, and nystagmus.

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?

cerebral angiography The nurse would anticipate a cerebral angiography, which detects distortion of the cerebral arteries and veins . A milligram detects abnormalities of the spinal canal. An electroencephalogram records electrical impulses of the brain. An echoencephalography is an ultrasound of the structures of the brain.

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

decreased muscle tone. A client with a lower motor neuron lesion would be expected to have decreased muscle tone. Those with upper motor neuron lesions would have hyperactive reflexes, no muscle atrophy, and muscle spasticity.