N504 ch. 24 cranial nerves

The nurse assesses the patient's deep tendon reflexes to be very brisk and hyperactive, with clonus. Which grade would the nurse enter in the patient's medical record? 1+ 2+ 3+ 4+

4+ The nurse assesses the deep tendon reflexes to determine the intactness of the reflex arcs at the specific spinal levels. The nurse measures the reflex response on a 4-point scale. The nurse documents very brisk and hyperactive responses with clonus as grade 4+. This indicates that the patient has an upper motor neuron lesion. Grade 3+ responses are brisker than the average response. The nurse records average and normal responses as grade 2+. The nurse documents a diminished reflex that occurs only with reinforcement as a grade 1+ reflex. p. 648

Which percentage of the population has a dominant left hemisphere, including those who are left-handed? 70% 75% 87% 95%

95% The left hemisphere is dominant in about 95% of people, including those who are left-handed. More than 70%, 75%, and 87% of people have a dominant left hemisphere. p. 625

Which assessments are included in the Glasgow Coma Scale? Select all that apply. Eye opening Pulse rate Verbal response Blood pressure Motor response

Eye opening Verbal response Motor response The Glasgow Coma Scale is an accurate and reliable quantitative tool that defines the level of consciousness by giving it a numeric value. The scale is divided into three areas: eye opening, verbal response, and motor response. Each area is scored separately. The total score reflects the functional level of the brain. A fully alert healthy person has a score of 15, whereas a score of 7 or less reflects coma. Although assessments of the vital signs are important for a critically ill person, pulse rate and blood pressure are unreliable parameters of central nervous system deficit. Any changes are late consequences of rising intracranial pressure. p. 656

In which location would the nurse test a patient's superficial reflex? Elbow Calf muscle Quadriceps Sole of the foot

Sole of the foot The superficial, or cutaneous, reflex is instigated by stroking the sole of the foot; plantar flexion is the normal response. The calf muscle can be assessed for clonus. Deep tendon reflexes are assessed in the quadriceps and the elbow. p. 645

Which lobe of the brain is associated with language comprehension? Frontal Parietal Occipital Temporal

Temporal Wernicke's area, present in the temporal lobe, is associated with language comprehension. The frontal lobe controls the emotions and behaviors of a patient. The postcentral gyrus of the parietal lobe contains the primary center responsible for sensation. The occipital lobe contains the center that is responsible for vision. p. 625

Which statement describes the efferent fibers? Sensory neurons carrying impulses from receptors Motor neurons influencing or modifying the lower motor neurons Motor neurons carrying impulses to the muscles, organs, and glands Motor neurons originating in the motor cortex and traveling to the brainstem

Motor neurons carrying impulses to the muscles, organs, and glands A nerve is a bundle of fibers outside the central nervous system (CNS). The efferent fibers are the peripheral motor nerves; these nerves deliver output from the CNS to target organs such as the muscles, organs, and glands. Sensory afferent fibers carry input to the CNS from the receptors. Upper motor neurons are complex descending motor fibers that can influence or modify the lower motor neurons. The pyramidal tract consists of motor nerve fibers that originate in the motor cortex and travel to the brainstem. p. 625

With the eyes closed, the patient is unable to identify by touch a key that is placed in the hand. The nurse uses which term to document this finding? Clonus Torticollis Astereognosis Hyperreflexia

Astereognosis A normal individual will be able to identify the object by touch, without seeing it. The patient with a sensory cortex lesion may have decreased sensory perception. Astereognosis refers to the patient's inability to identify the object by touch. Rapid and rhythmic contractions of the same muscles indicate clonus. An abnormal, asymmetrical head or neck position is a sign of torticollis. Overactive or overresponsive reflexes indicate hyperreflexia in the patient. p. 647

The nurse anticipates the patient with a Glasgow Coma Scale (GCS) score of 3 to be in which condition? Fully alert Comatose Obtunded Able to perform commands

Comatose A score of 7 or less on the GCS indicates that the patient is in a comatose condition; a score of 3 is given to a patient who is totally unresponsive. A fully alert patient should have a GCS score of 15. A patient who is able to obey commands would receive a GCS score of more than 6. The obtunded patient is not comatose but is also not fully alert. p. 656

Patients with which condition are at an increased risk for hemorrhagic stroke? Hemophilia Endocarditis Atrial fibrillation Atherosclerosis

Hemophilia The patient with hemophilia will have a defect in the coagulation cascade, which can lead to a hemorrhagic stroke. Endocarditis and atrial fibrillation may lead to the formation of a moving clot or embolus in the blood vessels. Atherosclerosis may lead to the formation of a thrombus in the blood vessels. Therefore endocarditis, atrial fibrillation, and atherosclerosis are associated with ischemic stroke, but not hemorrhagic stroke.

Which condition in the 3-year-old child prompts the nurse to suspect pyramidal tract disease? Extension of the limbs Positive Babinski reflex Presence of a Moro reflex Asymmetry in upper limb movements

Positive Babinski reflex The Babinski reflex is present at birth and disappears by the age of 24 months. The presence of a Babinski reflex after 2 or 2.5 years of age indicates that the child has impaired function of the pyramidal tract. The child with pyramidal tract disease may have decreased functioning of the spinal cord. Extension of the limbs is a sign of intracranial hemorrhage. The presence of a Moro reflex after 5 months of age indicates severe central nervous system injury. However, central nervous system injury may not lead to pyramidal tract disease in the child. Asymmetry of the upper limb movements indicates brachial plexus palsy, not pyramidal tract disease. p. 662

Which type of basic reflex includes the pupillary response and accommodation? Visceral Superficial Pathologic Deep tendon

Visceral There are four types of basic reflexes: the deep tendon reflexes, superficial reflexes, visceral reflexes, and pathologic reflexes. The pupillary response to light and accommodation falls under the category of visceral reflexes. While assessing this reflex, the nurse shines a penlight in the patient's eye and checks if the pupils constrict immediately. The knee jerk falls under the category of a deep tendon reflex. Superficial reflexes include the corneal reflex and the abdominal reflex. Pathologic reflexes are abnormal and may indicate a disease; these reflexes include the Babinski reflex and the Kernig reflex. p. 630

The patient with cerebellar damage will likely experience a change in which characteristic? Libido Memory Thermoregulation Voluntary movements

Voluntary movements The cerebellum is a part of the brain concerned with motor coordination of voluntary movements, equilibrium, and muscle tone. Any damage to the cerebellum may lead to the impairment of voluntary movements or motor functions in the patient. The function of the hypothalamus is the maintenance of temperature, appetite, sex drive, heart rate, and blood pressure; therefore the patient may have loss of libido and impaired thermoregulation when there is damage in the hypothalamus. The function of the cerebral cortex is to govern thought processes, memory, reasoning, and sensation; therefore the patient with cerebral cortex injury or damage may have complete or partial loss of memory. p. 625

Which instruction would the nurse give the patient to perform the Romberg test? "Walk heel to toe across the room." "Pronate and supinate the hands rapidly." "Run the heel of the foot down the opposite shin." "Stand with feet together and eyes open then closed."

"Stand with feet together and eyes open then closed." During the Romberg test, the nurse asks the patient to stand up with the feet together and arms at the sides. Once in a stable position, the nurse instructs the patient to close the eyes and to hold the position and wait for about 20 seconds. Normally, a patient can maintain posture and balance even with the visual-orienting information blocked, although slight swaying may occur. A positive Romberg sign is the loss of balance that occurs when closing the eyes. The nurse asks the patient to run the heel of the foot down the opposite shin to test cerebellar coordination and fine motor movements. Gait is evaluated by observing the patient walk heel to toe across the room. Rapid pronation and supination of the upper extremities tests abnormalities in diadochokinesia. p. 643

Which reflex helps the nurse assess the functioning of cranial nerve VIII (vestibulocochlear nerve) in an infant? Gag Sucking Optical blink Acoustic blink

Acoustic blink Cranial nerve VIII, or the vestibulocochlear nerve, aids in the transmission of impulses from the inner ear to the brain. The infant blinks in response to a loud hand clap 30 cm from the head. This is known as the acoustic blink reflex, and it helps determine the functioning of cranial nerve VIII. Cranial nerve X controls the function of the pharyngeal muscles. The gag reflex helps assess the functioning of cranial nerve X. Cranial nerve V innervates the muscles of the jaw. The sucking reflex enables the nurse to assess the functioning of cranial nerve V. The optical blink reflex helps assess the functioning of cranial nerves I, III, IV, and VI, because these nerves control the intraocular and extraocular muscle functions. p. 657

Which action by the student nurse assessing a patient's pain perception requires correction? Using a sharp edge of a tongue blade to test pain Discarding the tongue blade after the assessment Maintaining a 2-second gap between each pain stimulus Applying the tongue blade on the patient's body in a systematic order

Applying the tongue blade on the patient's body in a systematic order While assessing pain perception, the nurse breaks a tongue blade lengthwise and applies the sharp end to the patient's body randomly and unpredictably, but not in a regular order. This enables the nurse to assess pain perception in the patient accurately. The nurse uses the sharp edge of the tongue blade to test pain and the blunt end for assessing general responses. The nurse rightly discards the tongue blade to prevent the spread of infection to other patients. The nurse maintains a 2-second gap between each stimulus to avoid summation of the pain responses. p. 645

Which type of tremor is common in a patient with cerebral palsy? Chorea Athetosis Familial Intention

Athetosis Athetosis is a type of tremor that occurs in the patient with cerebral palsy and is characterized by slow, twisting, writhing, continuous movements resembling those of a snake or worm. It involves the distal part of the limb more than the proximal part of the limb. Sudden rapid, jerking movements of the limbs, trunks, or face indicate chorea. Chorea is common in the patient with Huntington's disease. Intention tremors are involuntary contractions of the muscles that worsen during voluntary movements and are common in the patient with cerebellar disease or multiple sclerosis. Familial tremor is a type of intention tremor that is common in older adult patients. p. 673

The patient on long-term therapy for seizures has a staggering gait and positive Romberg sign. Which type of medication is probably responsible for this patient's symptoms? Barbiturate Anticonvulsant Antipsychotic Dopaminergic

Barbiturate The health care provider may prescribe sedative medications such as barbiturates for the patient who is on long-term therapy for seizures. The cerebellum controls the balance and motor functions. Barbiturates such as phenobarbital (Luminal) directly act on the cerebellum and decrease its activity. Therefore the patient who is on long-term barbiturate therapy may have a staggering gait and impaired balance, or positive Romberg sign. Anticonvulsant drugs such as phenytoin (Dilantin) are antiseizure medications that help treat epilepsy or seizure disorder. Inability to sleep, weight loss, and decreased appetite are side effects of these drugs. Chlorpromazine is an antipsychotic medication; it may not be present in the prescription of a patient who has seizures. Dopaminergic drugs such as levodopa (Sinemet) increase the dopamine levels in the brain; they do not depress the cerebellum. Therefore they do not cause staggering gait and impaired balance in the patient. p. 675

Which assessments indicate that the patient is in the tonic phase of a generalized seizure? Select all that apply. Bites the tongue Tachycardia Facial grimacing Persistent confusion Opening of the mouth and the eyes

Bites the tongue opening of the mouth and eyes Excessive and abnormal neuronal activity in the brain may cause seizures in the patient. The different phases of a generalized seizure include loss of consciousness followed by the tonic phase, clonic phase, and postictal phase. During the tonic phase the patient will have muscle rigidity and may bite the tongue, open the eyes and mouth, and cry in a high-pitched voice. Increased heart rate, facial grimace, and violent muscular contractions characterize the clonic phase. The postictal phase is the last phase of a generalized seizure, and is characterized by deep sleep, disorientation, and confusion. p. 674

The patient reports a loss of pain and temperature sensation in the right lumbar region and has also lost the sensations of vibration and position discrimination on the left side of the lumbar region. The nurse anticipates which diagnosis? Chorea Flaccid quadriplegia Peripheral neuropathy Brown-Séquard syndrome

Brown-Séquard syndrome Brown-Séquard syndrome is characterized by the loss of the sense of pain and temperature on the contralateral side of the lesion and the loss of vibration and position discrimination on the ipsilateral side, below the level of the lesion. Chorea is characterized by abnormal rapid, jerky, purposeless movements of the limbs, trunks, or face. The patient with chorea may not have decreased sensory perception. Peripheral neuropathy is characterized by loss of sensation in the upper and lower limbs. Flaccid quadriplegia refers to the paralysis of all four extremities and the complete loss of the muscle tone, but not decreased sensory perception. p. 678

Which disorder would the nurse suspect in the patient who cannot touch the tip of the nose with the forefinger and loses balance when the eyes are closed? Bell palsy Hypoesthesia Meningeal irritation Cerebellar dysfunction

Cerebellar dysfunction The cerebellum is concerned with the motor coordination of voluntary movements, equilibrium, and muscle tone. The postural balance of the body and complex and quick muscular coordination are its major functions. Hypoesthesia is a disorder in which the patient's touch sensation is decreased. Bell palsy occurs because of a lower motor neuron lesion and causes paralysis of an entire half of the face. Meningeal irritation may lead to abnormal posture. Prolonged arching of the back, with head and heels bent backward, indicates meningeal irritation. p. 677

A lesion in which part of the brain is suspected in the patient displaying decorticate posturing? Midbrain Cerebrum Upper pons Cerebral hemispheres

Cerebral hemispheres The patient with lesions in the hemispheres of the cerebral cortex may show decorticate posture, which involves flexion of the arms, extension of the lower extremities, and plantar flexion. The patient with cerebral damage may have difficulties associated with memory and thinking. Because of differential functions of the midbrain and pons, a lesion in the midbrain and upper pons may result in decerebrate posture, not decorticate posture. p. 680

Which findings would the nurse observe in a patient with flaccid quadriplegia? Select all that apply. Hyperextension of the back Prolonged arching of the back Complete loss of muscle tone Paralysis of all four extremities Prolonged adduction of the arm

Complete loss of muscle tone Paralysis of all four extremities Flaccid quadriplegia may occur as a result of a neurologic disease or trauma. Flaccid quadriplegia refers to complete loss of muscle tone and paralysis of all four extremities. It is caused by a completely nonfunctional brainstem. Prolonged adduction of the arm may occur in the patient with decorticate rigidity. A hyperextended back may occur with decerebrate rigidity. Prolonged arching of the back is a characteristic finding of the opisthotonos posture, which is caused by meningeal irritation. p. 680

The nurse is helping stabilize a patient who is experiencing a generalized seizure with tachycardia and violent muscular contractions. Which symptoms would the nurse expect to see once these symptoms cease? Select all that apply. Confusion Disorientation Muscular rigidity High-pitched cry Loss of consciousness

Confusion Disorientation Excessive, hypersynchronous discharging of neurons in the brain may cause seizures. During the clonic phase of the seizure, the patient would have an increased heart rate and violent muscular contractions. During the postictal phase, which occurs directly after the clonic phase, the brain starts to recover from the seizure and the patient may experience confusion, disorientation, and often a deep sleep. Muscular rigidity occurs in the tonic phase of the generalized seizure, and during this phase the patient may have a high-pitched cry. Loss of consciousness occurs during the initial phase of a generalized seizure. p. 674

The nurse notes the absence of corneal, abdominal, and cremasteric reflexes on the right side of the patient's body with spastic paralysis on the left side of the body. Which is the probable reason for this condition? Defect in cranial nerve IX Demyelination of neurons Lower motor neuron damage Damage to the corticospinal tract

Damage to the corticospinal tract The absence of the abdominal and cremasteric reflexes on right side and spastic motor paralysis on the left side indicate that the patient has hemiplegia because of an affliction of the left corticospinal tract. Cranial nerve IX mediates the process of swallowing; a defect in or damage to cranial nerve IX may cause difficulty in swallowing, not hemiplegia. This would not lead to motor impairment on one side of the body. Demyelination of neurons may lead to multiple sclerosis, but not hemiplegia. Lower motor neuron damage causes flaccid paralysis, not spastic paralysis. p. 680

Which test helps screen the gross and fine motor coordination skills of a child? Weber Denver II Romberg Heel-to-shin

Denver II The Denver II test helps screen the gross and fine motor coordination skills in an infant. This test enables the nurse to assess whether the infant has achieved age-specific developmental motor skills. The nurse performs the Weber test to assess hearing ability of a patient. The Romberg test helps assess the upright postural control in the patient. The nurse uses the heel-to-shin test to check the lower extremity coordination. These tests are performed in older children and adults. p. 658

The nurse observes an older adult patient experience tremors while reaching for a pen. No tremors are noted at rest. Which medication would the nurse anticipate administering to the patient? Diazepam (Valium) Levodopa (Sinemet) Ibuprofen (Ultraprin) Chlorpromazine (Largactil)

Diazepam (Valium) Familial or essential tremors are common in older adults and occur when reaching for an object or other voluntary movement. These tremors can cause emotional stress to the patient and are relieved by sedatives such as diazepam (Valium). Levodopa (Sinemet) increases the levels of dopamine in the brain; therefore it is beneficial for the patient with Parkinson disease. Chlorpromazine (Largactil) reduces psychotic symptoms. It has no effect in treating tremors. Ibuprofen (Ultraprin) is an anti-inflammatory agent that helps reduce the pain associated with musculoskeletal disorders. It has no effect on reducing tremors. p. 673

Degeneration of which structure would the nurse suspect in the patient with resting tremors, abnormally slow movement, flat expression, reduced eye blinking, and slouched posture? Cerebral cortex Corticospinal tract Upper motor neurons Dopamine-producing neurons

Dopamine-producing neurons Resting tremors, slow movement (or bradykinesia), flat expression, reduced eye blinking, and slouched posture indicate parkinsonism in the patient. It is a neurodegenerative disease of the central nervous system. It occurs because of the degeneration of the dopaminergic neurons in the substantia nigra of the brain. Damage to the cerebral cortex may cause cerebral palsy, but not parkinsonism. The patient with cerebral palsy may have seizures, but not resting tremors. Damage to the corticospinal tract and degeneration of the upper motor neurons may result in hemiplegia, which refers to the contralateral paralysis of the upper and lower limbs. The patient with hemiplegia will not necessarily have slouched posture. The patient with hemiplegia may have a posture characterized by an adducted shoulder, flexed elbow, pronated wrist, and extended leg. p. 677

Which conditions are characteristic of lower motor neuron lesions? Select all that apply. Spasticity Hyperreflexia Fasciculation Muscular atrophy Loss of superficial abdominal reflexes

Fasciculation Muscular atrophy Marked muscular atrophy occurs mostly because of lower motor neuron lesions, whereas upper motor neuron lesions may cause little or no atrophy. Fasciculation refers to rapid and continuous twitching of the muscles. This occurs because of muscular atrophy and muscle weakness in a patient with lower motor neuron lesions. Spasticity refers to hypertonicity of the muscles. Lower motor neuron lesions may lead to hypotonia of the muscles, resulting in flaccidity. Lower motor neuron lesions may result in hyporeflexia or areflexia, but not hyperreflexia. Lower motor neurons do not control superficial reflexes such as the abdominal reflex. Loss of superficial abdominal reflexes may occur in the patient with upper motor neuron lesions. p. 676

Which muscle tone abnormality would the nurse anticipate in a patient with Guillain-Barré syndrome? Rigidity Flaccidity Spasticity Cogwheel rigidity

Flaccidity Guillain-Barré syndrome is a polyneuropathy that affects the lower motor neurons. In this condition, there is a decrease in the muscle tone, which leads to flaccidity. Rigidity indicates a constant state of resistance. The patient with Parkinson disease may have muscle rigidity. Upper motor neuron injury causes spasticity in which the muscle tone is increased. The patient with parkinsonism may have cogwheel rigidity, in which increased tone is released intermittently with passive motion. p. 672

How would an adult patient normally respond to the plantar reflex? Flexing the toes Flexing the elbow Extending the great toe Extending the lower leg

Flexing the toes The normal response to plantar reflex is flexion of the toes and inversion and flexion of the forefoot. Extension of the big toe and fanning of all toes is an abnormal response; however, it is normal in infants. This positive Babinski sign occurs with upper motor neuron disease of the corticospinal or pyramidal tract. If the stretched tendons of the flexed knee are struck just below the patella, extension of the lower leg will be the expected response. This is the quadriceps reflex. In the brachioradialis reflex, the relaxed forearm is stroked directly, about 2 to 3 cm above the radial styloid process. The normal response will be flexion and supination of the forearm. p. 652

Which response to the brachioradialis reflex test is documented as normal? Extension of the lower leg Extension of the forearm Dorsiflexion of the toes Flexion and supination of the forearm

Flexion and supination of the forearm The brachioradialis reflex originates at cervical vertebrae 5 and 6. The nurse holds the patient's thumbs to suspend the forearms in relaxation. The normal response to being struck directly on the forearm is flexion and supination of the forearm. When the stretched tendons of the flexed knee are stroked below the patella, extension of the lower leg is the expected response. This is the quadriceps reflex. Extension of the forearm is expected with the triceps reflex. Dorsiflexion of the toes is an abnormal reaction. p. 650

The nurse observes a palmar grasp reflex in an 8-month-old infant and anticipates which diagnosis? Nerve injury Frontal lobe lesion Occipital lobe damage Normal neurodevelopment

Frontal lobe lesion The nurse assesses the palmar grasp reflex in the infant by offering a finger to the infant from the ulnar side. If the infant grasps the finger tightly, it indicates the presence of palmar grasp reflex. This reflex appears at birth and disappears at the age of 3 to 4 months. Persistence of the palmar grasp beyond the age of 4 months may indicate the presence of a lesion in the frontal lobe. This reflex is not a common finding in the 8-month-old infant. Nerve injury may lead to the loss of the palmar grasp reflex. Damage to the occipital lobe will result in visual problems in the infant. p. 681

The nurse asks the patient to close the eyes and then traces the number 5 on the patient's palm. The patient is unable to identify the number even after repeated attempts. This finding could indicate damage to which part of the patient's brain? Cerebellum Sensory cortex Cranial nerve XII Dorsal spinothalamic tract

Graphesthesia refers to an individual's ability to read a number or a letter traced onto the skin without seeing it. The patient with lesions of the sensory cortex has impaired sensory perception and thus will not be able to identify the number or letter traced on the palm. The cerebellum controls the voluntary movements of the body; the patient with cerebellar damage may have impaired voluntary functions, but not decreased sensory perception. Cranial nerve XII (hypoglossal) innervates the tongue and mediates the speech, swallowing, and chewing processes. Therefore the patient with damage to cranial nerve XII would not have impaired graphesthesia. The patient with a lesion in the dorsal spinothalamic tract has a decreased sense of pain and temperature. Loss of graphesthesia sensation is not indicative of spinothalamic tract dysfunction. p. 674

Injury to which cranial nerve may cause anosmia in the patient? I (olfactory nerve) II (optic nerve) III (oculomotor nerve) IV (trochlear nerve)

I (olfactory nerve) Cranial nerve I, or the olfactory nerve, innervates the olfactory bulb and mediates the sense of smell. Therefore olfactory nerve injury may cause anosmia, or loss of the sense of smell in the patient. Cranial nerve II, which is also known as the optic nerve, innervates the eye and mediates the sense of vision. Therefore optic nerve damage may cause loss of vision in the patient. Cranial nerves III and IV, which are also known as the oculomotor and trochlear nerves, respectively, innervate the muscles that aid in the movement of the eyeball. Therefore damage to them may result in ptosis, or drooping eyelids. p. 638

The patient with multiple sclerosis may experience sequelae because of demyelination of which cranial nerves? Select all that apply. I II III VI VII

II III Multiple sclerosis is an immune-mediated disease in which axons undergo inflammation, demyelination, degeneration, and finally sclerosis. Cranial nerve II (the optic nerve) and cranial nerve III (the oculomotor nerve) frequently undergo demyelination in patients with multiple sclerosis, resulting in nystagmus and diplopia. Damage to cranial nerve I (the olfactory nerve) may occur as a result of fracture of the cribriform plate, a lesion in the frontal lobe, or as a result of the presence of a tumor in the olfactory bulb. A tumor in the brainstem may cause damage to the abducens, or cranial nerve VI. Damage to cranial nerve VII, the facial nerve, is associated with Bell palsy, but not multiple sclerosis. p. 671

Which statement describes decerebrate rigidity? Arms are flexed, and the legs are extended. Back is hyperextended, and the palms are pronated. Muscle tone is lost, and all four extremities are paralyzed. Back is arched, and the head and heels are bent backward.

In decerebrate rigidity, the upper extremities of the patient are stiffly extended and adducted. The palms are pronated, the teeth are clenched, and the back is hyperextended. It indicates a lesion in the brainstem at the midbrain or upper pons. In decorticate rigidity, the arms are flexed and adducted (i.e., tight against the thorax), and the legs are extended with plantar flexion. This indicates a hemispheric lesion of the cerebral cortex. In flaccid quadriplegia, complete loss of muscle tone and paralysis of all four extremities occur. It indicates a completely nonfunctional brainstem. Prolonged arching of the back, with the head and heels bent backward, is a symptom of opisthotonos. This indicates meningeal irritation. p. 680

In which patient would the nurse expect to find a palmar grasp reflex and a positive Babinski reflex? Infant Child Adolescent Adult

Infant The palmar grasp and Babinski reflexes are primitive reflexes originating in the central nervous system that are exhibited by healthy infants in response to particular stimuli. These reflexes disappear or are inhibited by the frontal lobes as the infant moves through normal child development. Persistence of the palmar grasp reflex after 4 months occurs because of a frontal lobe lesion. A normal infant older than 4 months should not exhibit the palmar grasp reflex. The Babinski reflex is present at the time of birth and disappears when the infant reaches the age of 24 months. A positive Babinski reflex after 2 or 2½ years of age occurs with pyramidal tract disease. A normal adolescent or adult should exhibit normal reflexes but not palmar grasp reflex or Babinski reflex. p. 661

The presence of which pathologic reflexes prompt the nurse to suspect meningeal irritation? Select all that apply. Kernig Gordon Babinski Brudzinski Oppenheim

Kernig Brudzinski's The nurse may observe Kernig and Brudzinski reflexes in the patient with meningeal irritation, which may be caused by meningeal infections or tumors. The patient with meningeal irritation may show resistance to straightening the leg while in supine position. This indicates a positive Kernig sign. A patient with a positive Brudzinski neck sign is characterized by resistance and pain in neck, with flexion of the hips and knees. Gordon sign, Babinski reflex, and Oppenheim sign are observed in the patient with pyramidal tract disease. Squeezing of the calf muscles may cause extension of the great toe and fanning of the other toes. This indicates a positive Gordon sign. Extension of the great toe and fanning of the toes upon stroking of the lateral aspect of the foot indicates positive a Babinski reflex. The nurse strokes the anterior tibial muscle while assessing the Oppenheim reflex in the patient. Extension of the great toe along with fanning of the toes indicates a positive Oppenheim sign. p. 680

Which tract of the central nervous system carries the sensations of pain and temperature? Extrapyramidal Lateral spinothalamic Anterior corticospinal Anterior spinothalamic

Lateral spinothalamic The spinothalamic tract contains sensory fibers that enter the dorsal root of the spinal cord and synapse with a second sensory neuron. Fibers carrying pain and temperature sensations ascend the lateral spinothalamic tract. Anterior corticospinal nerves are motor neurons that originate in the motor cortex and travel to the brainstem. The corticospinal tract permits humans to have skilled and purposeful movements. The extrapyramidal tracts include all the motor nerve fibers originating in the motor cortex. These subcortical motor fibers maintain muscle tone and control body movements. The anterior spinothalamic tract transmits crude touch sensations. p. 627

Which condition would the nurse suspect has caused the patient to experience stiff extension of the upper and the lower extremities, clenching of the teeth, and hyperextension? Meningeal irritation Lesion in the upper pons Lesion in the cerebral cortex Injury to the extrapyramidal motor tracts

Lesion in the upper pons Stiff extension of the upper and lower extremities, clenching of the teeth, and hyperextension of the back indicate decerebrate rigidity in the patient. A lesion in the upper pons of the midbrain may lead to the loss of certain motor reflexes, resulting in decerebrate rigidity. The patient with meningeal irritation may have an opisthotonos posture, but not decerebrate rigidity. Opisthotonos posture refers to the prolonged arching of the back with the head and heels bent backward. Lesions in the cerebral cortex may cause decorticate rigidity, but not decerebrate posture. Rigidity, associated with injury to the extrapyramidal motor tracts, is characterized by a constant state of resistance to passive movement in any direction. p. 680

A patient presents with prolonged arching of the back with the head and heels bent backward. Which condition would the nurse suspect in the patient? Meningeal irritation Brachial plexus palsy Lesions in the brainstem Lesions in the cerebral cortex

Meningeal irritation Prolonged arching of the back with the head and heels bent backward characterizes the opisthotonos posture. In this condition, meningeal irritation resulting from inflammation may lead to a decrease in the range of motion of the spine, leading to the prolonged arching of the back. The head of the patient may bend backward because of nuchal rigidity associated with the meningeal irritation. The patient with lesions in the brainstem may show extension of both upper and lower limbs, but not prolonged arching of the back. The patient with brachial plexus palsy may have asymmetry of upper limb movements, but not back hyperextension. The patient with lesions in the cerebral cortex may show flexion of the upper limbs and extension of the lower limbs, but not an opisthotonos posture. p. 680

Which signs point to a diagnosis of Alzheimer disease? Select all that apply. Diplopia Bradykinesia Mood swings Disorientation Loss of initiative

Mood swings Disorientation Loss of initiative Alzheimer disease is a neurodegenerative disorder, and the patient may have memory loss because of the death of neurons in the cerebral cortex and subcortical regions. The patient may also have rapid mood swings because of the death of nerve cells. The patient with Alzheimer disease may have disorientation regarding time and place because of damage to the neurons in the cerebrum. The patient may become passive because of a loss of initiative and thus may not participate in any social activities. The patient with multiple sclerosis may have diplopia because of the demyelination of the optic nerve, which is not a pathologic feature of Alzheimer disease. Bradykinesia is the characteristic sign of parkinsonism, but not Alzheimer disease. p. 670

Which reflex, if present in a 6-month-old infant, would prompt the nurse to immediately refer the patient to the provider? Moro Sucking Babinski Tonic neck

Moro When an infant is startled suddenly by jarring the crib or making a loud noise, the infant abducts and extends the arms and legs. This reflex, called the Moro reflex, is present at birth, but disappears by 4 months of age. If the nurse observed the Moro reflex in an infant as old as 6 months, this could indicate severe central nervous system injury and would warrant immediate attention. The sucking reflex, Babinski reflex, and tonic neck reflex are normal findings in a 6-month-old infant and would not be a cause for concern. The sucking reflex disappears at the age of 10 to 12 months. The Babinski reflex is present at birth and disappears by 24 months of age. The tonic neck reflex disappears by 4 to 6 months of age. p. 662

The nurse finds that a patient has crossed knees, fatigue, nystagmus, and diplopia. During the assessment, the nurse also observes that the patient is unable to maintain balance with the eyes closed. Which complication is present in the patient? Athetosis Myoclonus Meningitis Multiple sclerosis

Multiple sclerosis Multiple sclerosis occurs because of inflammation of the axons, which results in demyelination of the neurons in the brain and the spinal cord. Multiple sclerosis affects the cerebellar system of the brain in a major way. Therefore the patient will have impaired voluntary movements, which may lead to crossed knees and scissor gait. Because multiple sclerosis commonly involves demyelination of the optic nerves, the patient may have nystagmus and diplopia. The patient's inability to maintain balance after closing the eyes indicates a positive Romberg test. A positive Romberg test is a sign of multiple sclerosis. Slow, involuntary, convoluted, and writhing movements of the body resembling a snake indicate athetosis. The patient with athetosis might not have diplopia and nystagmus. Rapid, sudden jerking movements or a short series of jerks at regular intervals indicates myoclonus. It is caused by spinal cord injury or brain injury and is not associated with multiple sclerosis. The patient with meningitis may show an opisthotonos posture, but not crossed knees or scissor gait. p. 677

Damage to which cranial nerve can cause drooping of the upper eyelids in the patient with myasthenia gravis? Acoustic Olfactory Oculomotor Hypoglossal

Oculomotor The patient with myasthenia gravis may have ptosis, or drooping eyelids. The oculomotor nerve innervates the eye orbits and controls the movement of the eyes and eyelids. Therefore any damage to cranial nerve III may result in drooping eyelids. Cranial nerve I is the olfactory nerve. It innervates the nose and helps in sense of smell; therefore damage to this nerve may cause anosmia, but not drooping eyelids. The hypoglossal nerve innervates the tongue and controls its movement; damage to this nerve may cause difficulty in swallowing and speech, but not ptosis. The acoustic nerve innervates the ear and mediates the sense of hearing. Damage to this nerve may cause hearing impairment, but not ptosis. p. 671

Which response by the infant to having the nose pinched indicates a normally functioning cranial nerve XII? Wrinkles the forehead Blinks the eyes with rapid closure Opens the mouth and raises the tongue Cries with a symmetrical facial movement

Opens the mouth and raises the tongue The infant with normal functioning of cranial nerve XII opens the mouth and raises the tongue in the midline when the nurse pinches the nose. Cranial nerve VII aids in the movement of the facial muscles. Therefore the nurse checks for the forehead wrinkle while assessing the functioning of the cranial nerve VII. Cranial nerve IV aids in the movement of the eye muscles. Therefore the nurse expects blinking of the eye while assessing the function of the cranial nerve IV. The infant with normal cranial nerve VII function will have symmetrical facial movements while crying and smiling. However, the nurse will not check this while assessing for the cranial nerve XII.

Which test is used to assess for a sensory cortex lesion? Weber Point location Finger-to-nose Finger-to-finger

Point location The point location test helps assess the sense of touch, including the ability to localize the sense of touch. If a patient cannot pass this simple test, it could indicate a lesion in the sensory cortex. Cranial nerve VIII, or the vestibulocochlear nerve, transmits hearing impulses from the ear to the brain, and this function is tested by the Weber test. The finger-to-nose and finger-to-finger tests help assess muscle coordination. They help determine whether the patient has cerebellar dysfunction. p. 648

During the neurologic assessment, the nurse asks the patient to stand straight with the eyes closed. The nurse then instructs the patient to stretch out both arms with the palms facing up and to hold that position. The nurse observes that the patient's left palm starts turning downward within 10 seconds, though the patient can hold the right hand steady. Which condition would the nurse suspect? Athetosis Dysarthria Pronator drift Astereognosis

Pronator drift When a patient is unable to hold his or her palms upward for more than 20 seconds, it indicates that the patient has pronator drift. Pronator drift is a downward unilateral drift that occurs with mild hemiparesis. Athetosis refers to slow, twisting, writhing, continuous movements of the muscles, resembling those of a snake or a worm. Dysarthria refers to a difficulty in forming words. Astereognosis is the inability to identify objects by active touching with the hands. p. 654

Which tests would the nurse perform to assess cerebellar function in a patient? Select all that apply. Romberg Extinction Stereognosis Point location Finger-to-nose

Romberg Finger-to-nose The Romberg test is done to assess balance. The finger-to-nose test is done to assess upper limb coordination. This ability of an individual to perform these tests determines the cerebellar function of the patient. The extinction test is done to determine if an individual is able to perceive sensation upon touching both the sides of the body simultaneously. The stereognosis test is the ability of an individual to recognize objects by feeling their forms. The point location test is done to determine whether the patient is able to locate the area where he or she is touched. These tests are designed to assess the function of the sensory cortex. pp. 642-643

The reflex arc consists of which structures? Select all that apply. Nucleus Sensory nerve Motor nerve Cranial nerve Neuromuscular junction

Sensory nerve Motor nerve Neuromuscular junction The myotatic reflex is made up of five components. The intact sensory nerve acts as an afferent neuron. The efferent pathway is controlled by an intact motor nerve fiber. The efferent pathway ends in the neuromuscular junction. Apart from these, a functional synapse in the cord and a competent muscle are also present in a reflex arc. A cranial nerve originates in the brain and is not a component of the reflex arc. A nucleus is a brain structure consisting of a relatively compact cluster of neurons. A reflex arc does not involve the brain; it involves the spinal cord and afferent and efferent neurons. p. 630

For which conditions would the nurse assess in the patient unable to recognize the smell of coffee? Select all that apply. Sinusitis Allergic rhinitis Brainstem tumor Fracture of the cribriform plate Increase in intracranial pressure

Sinusitis Allergic rhinitis Fracture of the cribriform plate Sinus infection, or sinusitis, refers to the presence of inflammation in the paranasal sinuses. Allergic rhinitis refers to the inflammation of the nasal airways in response to allergy. Sinusitis and allergic rhinitis increase mucous secretions of the nasal cavity, resulting in nasal congestion. These conditions may decrease the sense of smell. A fracture of the cribriform plate may lead to the leakage of cerebrospinal fluid into the nose, resulting in a decreased sense of smell. A brainstem tumor and increased intracranial pressure might not affect the function of the olfactory center of the brain. The patient with a brainstem tumor may not be able to move the eyeball properly. The patient who has increased intracranial pressure may have a throbbing headache and a dilated, nonreactive pupil. pp. 637, 671

Which test involves the placement of a paper clip in the palm of a patient whose eyes are closed and asking him or her to recognize the object? Extinction Stereognosis Graphesthesia Discrimination

Stereognosis The stereognosis test determines the patient's ability to recognize familiar objects by feeling their forms, sizes, and weights without seeing them. In graphesthesia, a number is traced on the skin to test the patient's ability to "read" it. Graphesthesia is a good measure of sensory loss if the patient cannot make the hand movements that are needed for stereognosis. Such a problem may occur with arthritis. The nurse simultaneously touches both sides of the patient's body at the same point to perform the extinction test. Normally, both sensations are felt. The ability to recognize only one of the stimuli occurs with a sensory cortex lesion. The stimulus is extinguished on the side opposite to the cortex lesion. The discrimination test measures the discrimination ability of the sensory cortex. p. 628

The nurse flashes light into the eyes of a 5-year-old child and observes ocular misalignment and a deviated gaze. Which term would the nurse use to document this finding? Nystagmus Strabismus Horner's syndrome Myasthenia gravis

Strabismus Strabismus is a condition in which the eyes are not aligned with each other. It may be caused by extraocular muscle incoordination, which ultimately results in gaze deviation. Nystagmus refers to the involuntary back-and-forth oscillation of the eyeball. Ocular misalignment will not lead to nystagmus in the child. Horner's syndrome occurs because of the disruption of the sympathetic nerves that supply the eyes; it results in ptosis. Disruption of sympathetic nerves does not cause an alteration in the alignment of the eyes. Myasthenia gravis is a chronic condition that weakens various muscles of the body, including the eye muscles. This weakening leads to drooping of the eyelids, but not ocular misalignment. p. 638

Which is the major function of the glossopharyngeal nerve? Tasting of food Swallowing and gagging Lateral movement of the eye Muscular movement of the tongue

Swallowing and gagging The glossopharyngeal nerve is cranial nerve IX. Its major motor function is to help in swallowing. The gag reflex, also known as a laryngeal spasm, is a reflex contraction of the back of the throat, evoked by touching the roof of the mouth, the back of the tongue, the area around the tonsils, and the back of the throat; the sensory limb of cranial nerve IX predominantly mediates this reflex. Lateral movement of the eye is controlled by the abducens nerve, or cranial nerve VI. The sensory part of the vagus nerve (cranial nerve X) contributes to the ability to taste. The hypoglossal nerve (cranial nerve XII) controls the muscular movement of the tongue. p. 631

Which lobe of the brain is associated with personality and intellectual functioning? Frontal Parietal Occipital Temporal

The frontal lobe is associated with personality, behavior, emotions, and intellectual functioning. The parietal lobe is associated with the processing of sensory information such as pressure, touch, and pain. The occipital lobe is the primary visual receptor center. The temporal lobe is associated with the functions of hearing, taste, and smell. p. 625

The patient reports a sudden and severe throbbing headache and right arm weakness. Upon assessment, the nurse notes facial drooping and stuttered speech. The MRI reveals the development of an atherosclerotic plaque in the middle cerebral artery. The nurse anticipates the diagnosis of which type of stroke? Silent Embolic Thrombotic Hemorrhagic

Thrombotic A sudden and severe throbbing headache, arm weakness, and facial drooping indicate a cerebrovascular accident (CVA). The patient who is experiencing a CVA may also have difficulty in speaking. Atherosclerosis involves the formation of plaque on the inner walls of the arteries. This plaque may rupture and form a thrombus that blocks the blood vessels of the brain, resulting in a thrombotic stroke. The patient with a silent stroke may not experience any symptoms of the stroke. Embolic stroke occurs because of the presence of an embolus, or a movable clot, in the blood vessels. This is common in patients with atrial flutter or fibrillation. Hemorrhagic stroke may occur when there is bleeding from a weakened artery of the brain. p. 674

The patient with aphasia has lost which ability? Taste Smell Walk or stand Understand language

Understand language The inability to understand or use language is known as aphasia. It is caused by the dysfunction of Wernicke's area in the temporal lobe or Broca's area in the frontal lobe of the brain. Anosmia is the inability to perceive odor or a lack of functioning olfaction. Astasis is a lack of motor coordination marked by an inability to stand, walk, or even sit without assistance because of the disruption of muscle coordination. Ageusia is the loss of the taste functions of the tongue. A person with ageusia will be unable to detect sweetness, sourness, bitterness, or saltiness. p. 625

Which cranial nerve would the nurse assess by touching a cotton wisp to the patient's forehead, cheeks, and chin? IV V VI VII

V The nurse is testing the sensory function of cranial nerve V (or the trigeminal nerve) by touching a cotton wisp to the patient's face. This is the largest cranial nerve, and it performs sensory functions related to the nose, eyes, tongue, and teeth. This nerve is further divided into ophthalmic, maxillary, and mandibular branches. The patient's light touch sensation is tested by touching a cotton wisp to these designated areas while the patient's eyes are closed. Cranial nerve IV (or the trochlear nerve) is a motor nerve that is connected to the midbrain and controls the eye muscles and turning of the eye. Cranial nerve VI (or the abducens nerve) helps in the lateral movement of the eyes, and cranial nerve VII (or the facial nerve) is responsible for various facial expressions. Because all of these are motor nerves, the light touch sensation test is not required for these cranial nerves. p. 639

The nurse suspects damage to which cranial nerve in a patient who has an asymmetric smile and is unable to wrinkle the forehead? II (optic nerve) III (oculomotor nerve) VII (facial nerve) VIII (auditory nerve)

VII (facial nerve) Asymmetric facial movements and the inability to wrinkle the forehead indicate Bell palsy in a patient, which affects cranial nerve VII. Cranial nerve II innervates the eye and mediates the sense of vision. Therefore any damage to this nerve may lead to loss of vision, but not Bell palsy. Cranial nerve III innervates the muscles of the eyeball; its damage may lead to ptosis or eyelid drooping. Cranial nerve VIII innervates the ear and mediates the sense of hearing. Therefore its damage may lead to hearing impairment, but not Bell palsy. p. 639

The patient with difficulty swallowing and regurgitation of ingested fluids through the nose may have a lesion on which cranial nerve? III V X XII

X Cranial nerve X is also known as the vagus nerve, and it innervates the heart and the digestive tract. The patient with bilateral lesions on the vagus nerve may have difficulty swallowing, and the fluids may be regurgitated through the nose. Cranial nerve XII, also known as the hypoglossal nerve, innervates the tongue and controls the movement of the tongue. Therefore the patient with a cranial nerve XII lesion may have a slow rate of movement of the tongue. Cranial nerve V, also referred to as the trigeminal nerve, innervates the muscles of the jaw. Therefore the patient with a unilateral cranial nerve V lesion may have weakness of the jaw muscles. Cranial nerve III, also referred to as the oculomotor nerve, innervates the muscles of the eyeball. Therefore the patient with cranial nerve III paralysis may have dilated pupils and ptosis, or drooping eyelids. p. 631