Neurological Disorders

A client arrives in the emergency department after a bicycle crash. Which of the following assessment questions is most important for the nurse to ask? a. "Were you wearing a helmet?" b. "Have you had difficulty sleeping at night?" c. "Do you have a family history of diabetes?" d. "Do you take any herbal preparations?"

"Were you wearing a helmet?" Rationale: The nurse should ask if the client was wearing a helmet in order to assess the extent of injury. Difficulty sleeping does not relate to this case. It is important to know if the client has diabetes, but not the most important for this client. Taking herbal preparations is not relevant for this client's situation.

neuron

(basic cell of the nervous system) is made up of a dendrite, a cell body, and an axon

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? A An oral anticoagulant medication. B A beta-blocker medication. C An anti-hyperuricemic medication. D A thrombolytic medication.

A An oral anticoagulant medication. Thrombi form secondary to atrial fibrillation, therefore, an anticoagulant would be anticipated to prevent thrombi formation; and oral (warfarin [Coumadin]) at discharge verses intravenous. Beta blockers slow the heart rate and lower the blood pressure. Anti-hyperuricemic medication is given to clients with gout. Thrombolytic medication might have been given at initial presentation but would not be a drug prescribed at discharge.

Ultrasonography

A probe is placed against the cornea to measure for lens implant after cataract removal and to diagnose retinal detachment. *Nursing Implications* Explain to the patient that cornea is anesthetized before the procedure is done.

Positive emission tomography (PET)

A radioactive agent is injected, and computed tomography measures metabolic activity of the brain. Used to detect brain cancer, Alzheimer disease, epilepsy, and Parkinson disease. *Nursing Implications* Withhold food and fluids 4 hours before the exam. Explain that an IV line will be inserted. Post-test, encourage oral fluids to aid removal of radioisotope.

Visual field testing

A semicircular bowl-like instrument shows light in different parts of the bowl to map field of vision. Used to evaluate the progression of glaucoma. *Nursing Implications* Procedure does not cause pain but can tire the patient.

A 48-year-old male construction worker has come to the clinic with a complaint of something in his eye. The LPN/LVN assists the physician to stain the eye. She knows the physician will use fluorescein stain. This will identify what? a. Contusion b. Laceration c. Bruising d. Abrasion.

Abrasion. Rationale: Fluorescein dye is injected onto the cornea, and the cornea is viewed with a slit lamp. The green staining allows identification of corneal ulceration or abrasion. Contusion and bruising are characteristics of injury seen during skin assessment. A laceration to t

2. After electroencephalography (EEG), what nursing action should the nurse implement? a. Monitor for signs of bleeding at insertion site b. Encourage client to increase fluid intake c. Monitor for nausea and vomiting d. Assist client to shampoo hair

Assist client to shampoo hair. Rationale: Paste is used to attach electrodes to the scalp and should be washed out to increase client comfort. An EEG is noninvasive, so there is no insertion site. An EED does not cause nausea and vomiting. Increasing fluids is unnecessary after EEG, but cleaning paste out of the hair is appropriate.

What is the expected outcome of thrombolytic drug therapy? A Increased vascular permeability. B Vasoconstriction. C Dissolved emboli. D Prevention of hemorrhage

C Dissolved emboli. Thrombolytic therapy is use to dissolve emboli and reestablish cerebral perfusion.

Which of these physiologic results would occur from the stimulation of the sympathetic nervous system? Select all that apply. a. Decreased peristalsis b. Slower heart rate c. Dilation of skin blood vessels d. Increased blood glucose levels e. Dilation of the pupils f. Constriction of the bronchi

Decreased peristalsis. Increased blood glucose levels. Dilation of the pupils. Rationale: The sympathetic nervous system decreases peristalsis, increases blood glucose levels, and dilates the pupils. Slowing of the heart rate is an action of the parasympathetic nervous system. Dilation of skin blood vessels is an action of the parasympathetic nervous system.

fissures

Deep grooves separate the hemispheres and sepa- rate the cerebrum from the cerebellum.

Ultrasound

Echoes from high-frequency sound waves are used to study blood flow within a vessel.t

II Optic

Vision

IV Trochlear

Eyeball movement

ectropion

Eyelid muscles may lose tone, causing the lower lid to turn out

The LPN/LVN knows that an elderly client that is homebound is at risk for safety issues and impaired self-care. This is due to: a. loss of their spouse b. hearing and vision impairment c. lack of motivation due to aging d. inability to socialize

Hearing and vision impairment. Rationale: As clients age, hearing and vision impairment increases the risk for injury and safety issues. Loss of a spouse can be devastating but usually does not increase safety issues as long as the widow/widower is still able to perform ADLs. Lack of motivation and social isolation can be indicators of depression.

VI Abducens

Lateral movement of the eyeball

right-Hemisphere CVa

Left hemiplegia Left visual field deficits Spatial-perceptual deficits Denies or unaware of deficits Easily distracted Poor judgment Impulsive

Magnetic resonance imaging (MRI)

MRI uses a super magnet and radiofrequency signals to elicit a response from hydrogen nuclei. Used to identify stroke, tumor, trauma, multiple sclerosis, and seizures. *Nursing Implications* The patient is not exposed to radiation during an MRI. Assess for metal implants such as pacemaker, shrapnel, or body piercing. Provide teaching, as the experience can be frightening

VII Facial

Movement of facial muscles Secretions from lacrimal and salivary glands Taste in anterior two-thirds of tongue

XI Accessory

Neck and shoulder movement

III Oculomotor

Pupil constriction Eyeball movement Raising of upper eyelid

left-Hemisphere CVa

Right hemiplegia Right visual field deficits Aphasia Aware of deficits Impaired intellectual ability Slow, cautious behavior High level of frustration over losses

Which nursing diagnosis has the highest priority for a client with status epilepticus? a. Anxiety b. Risk for Injury c. Risk for Ineffective Airway Clearance d. Risk for Ineffective Cerebral Tissue Perfusion

Risk for Ineffective Airway Clearance.

V Trigeminal

Sensation of the scalp, nose, mouth, and cornea Chewing

I Olfactory

Smell

Computed tomography (CT) scans

Specialized radiographic procedures that produce computer-generated images with significantly more detail than standard x-rays allow. May be done with or without contrast medium. Detects problems such as hemorrhage, edema, hematoma, infarction, tumor, brain abscess, aneurysm, as well as size and location of cerebrovascular accident (CVA). *Nursing Implications*

X Vagus

Swallowing

presbyopia.

The lens becomes less elastic, affecting near vision. (Patients with presbyopia may feel that their arms have become too short to read the newspaper comfortably.)

entropion

The lid margin may turn inward causing the lashes to irritate the eye.

Cerebral arteriogram

identifies vessel abnormalities such as an aneurysm.

Neglect syndrome (or unilateral neglect):

The patient ignores the affected side of the body; tends to bump into walls, walk to one side, or fail to dress the affected side.

Audiometry

The patient wears earphones through which sounds are presented to determine the hearing range. Used to diagnose conductive hearing loss. *Nursing Implications* Explain that the test is done by an audiologist

Diagnostic tests - complete blood count (CBC) with differential and cultures from blood, urine, throat, and nose

To identify infectious diseases such as meningitis or encephalitis

XII Hypoglossal

Tongue movement

Evoked potentials

Visual or auditory stimulus evokes electrical activity related to nerve conduction along sensory pathways. Electrodes on the scalp and skin record the activity level. Done to diagnose multiple sclerosis, acoustic neuroma, Parkinson disease, spinal cord disease, or blindness. *Nursing Implications* Instruct the patient to wash hair before the exam.

X-ray and CT scan

X-rays and CT scan are used to evaluate the auditory canal for diagnosing Ménière disease. *Nursing Implications* Explain procedure to the patient.

Which of the following risk factors in the client's history is most likely to increase the potential in developing a CVA? Select all that apply. a. Age 50 or older b. Use of oral contraceptives for the past 10 years c. Presence of atherosclerosis d. Consumption of one beer per day e. Overweight by 50 pounds f. Of Caucasian race

Use of oral contraceptives for the past 10 years. Presence of atherosclerosis. Overweight by 50 pounds. Rationale: Use of birth control pills, atherosclerosis, and obesity increase stroke risk. Persons older than 65, not 50, have increased risk for CVA. Those with excessive, not low, alcohol intake have higher risk for CVA. African Americans, not Caucasians, have higher risk for CVA.

Skull and spine x-rays

Used to identify fractures, bone erosion, and calcifications. *Nursing Implications* Noninvasive test. Explain if different positions are needed.

Radiography

Used to identify neurologic abnormalities such as lesions and tumors; when combined with use of an injected contrast medium, used to study blood flow through vessels. *Nursing Implications* If contrast medium is used, ask about allergies to iodine and seafood before the exam; ensure good hydration before and after the exam to reduce the risk of kidney damage. Although noninvasive, radiography exposes the patient to potentially damaging radiation. Ask women of childbearing age about possible pregnancy before the exam.

Which one of the following self-care strategies should the nurse teach to the client with trigeminal neuralgia? a. Increase fluid intake b. Chew on the affected side c. Monitor calorie intake d. Ways to avoid trigger points

Ways to avoid trigger points. Outcome 5. Rationale: Clients must understand that stimulating trigger points can initiate an attack. They are taught to chew on the unaffected side unless they cannot eat; then, a high-calorie, high-protein diet is needed. Clients with trigeminal neuralgia would not be taught to monitor calories but to ingest high-protein, high-calorie foods. Fluids do not need to be increased.

Myelogram

X-ray of spinal cord and canal after injection of contrast medium. Identifies spinal cord tumors, herniated intervertebral disks, and arthritic bone spurs. *Nursing Implications* Closely monitor neurologic and vital signs. Immediately report leakage or bleeding from lumbar puncture site to the charge nurse and physician.

Facial x-rays and CT scan

X-rays and CT scan are used to identify orbital fractures or the presence of foreign bodies in the eye. *Nursing Implications* Explain procedure to the patient.

Global aphasia:

a combination of expressive and receptive aphasia.

CVA Diagnosis begins with

a complete history and physical examination. The time of the onset of stroke manifestations is an essential part of the assessment.

conjunctiva,

a thin mucous membrane that covers the anterior surface of the eye, also lines the inner surfaces of the eyelids.

myelin sheath

a white fatty substance

Expressive aphasia:

an inability to speak or write due to damage of Broca area. The patient usually can under- stand what is being said.

Receptive aphasia:

an inability to understand the spoken word due to damage of Wernicke area. The patient can speak, but the words do not make sense.

Deep tendon reflexes

are assessed at the wrists, elbows, knees, and Achilles ten- don with a reflex hammer.

blood-brain barrier i

astrocytes that are joined by tight junctions. This decreases permeability so that harmful substances in the blood can- not enter the brain. It allows only the passage of lipids, glu- cose, some amino acids, carbon dioxide, oxygen, anSubstances such as urea, creatinine, some toxins, and most antibiotics cannot pass this barrier. However, brain injury or infection may cause a local breakdown of the barrier.

focused physical examination for the patient with a neurologic problem

begins by assessing the patient's pos- ture, movement, and appearance and identifying orienta- tion, mental state, and emotional state. Identify whether the patient can see, hear, and feel your touch. Assess dress, hygiene, and grooming, as well as gait and posture. Observe the patient's actions and affect. Note the LOC; content and quality of speech; mood swings; person- ality changes; and orientation to time, place, and person. Assess for memory or perceptual deficits. Obtain blood pressure in both arms (unless contraindi- cated), pulse, respiratory rate, and temperature. Note any abnormal breathing patterns such as increased or decreased rate and depth of breathing. Check pupil response to light by using a penlight. Normal response should be PERRLA (pupils equally round and reactive to light and accommodation). Observe for ptosis (drooping eyelids) and nystagmus (involuntary eye movement). Assess the ability to swallow a small drink of water, noting the presence of dysphagia (difficulty swallowing). Determine the patient's ability to shrug the shoulders and stick out the tongue. Note that the tongue should be midline. Assess for facial droop. Have the patient turn head side to side against resistance. Perform the Romberg test. Assess upper and lower extremities for weakness, atrophy, and tremors, as well as identifying decreased muscle tone (flaccidity) or increased muscle tone (spasticity). Ask the pa- tient to squeeze your hands, push feet against the resistance of your hands, and raise both legs off the bed. Note if thereis any difference between left and right side. Assess gait and ability to stand on one foot and walk heel to toe. ataxia is a lack of coordination and an unbalanced gait. Assess DTRs. Abnormal DTRs require further medical evaluation. Assess distant vision by using the Snellen chart (see Figure 5-4) and asking the patient to cover one eye at a time to read the chart and then repeat the test for the other eye. Assess near vision in the same manner, using a Rosenbaum chart (Figure 37-11▪). To test extraocular movements, ask the patient to follow a pen or your finger while keeping the head stationary. Inspect the eyelids for unusual redness or discharge. Note abnormal wideness of the lids, which may be due to ex- ophthalmos. Inspect the cornea and iris for cloudiness or irregu- larities and the sclera for redness or yellow discoloration. Assess for hearing loss by performing the whisper test and the Rinne and Weber tests (see Box 40-9). Inspect the auricle for redness, drainage, scales, or skin lesions. Palpate the auricles and over the mastoid process for tenderness, swelling, or nodules.

Normal CSF

clear, is colorless, and contains no RBCs, a few WBCs, very little protein, and glucose of 50 to 70 mg/dL.

reflex arc

consists of a receptor, an afferent sensory neuron, the response center in the spinal cord or brain, an efferent motor neuron, and an effector muscle or gland

Stretch reflexes

control muscle tone and help maintain posture.

The right hemisphere

controls sensation and movement of the left side of the body, whereas the left hemi- sphere controls sensation and movement of the right side of the body. controls visual-spatial information such as art, music, and the surrounding physical environment.

MRI

detects areas of infarction earlier than a CT scan.

Dysarthria:

difficulty in speech caused by paralysis of the muscles that control speech.

Diagnostic tests - blood glucose level

done to identify the presence of hypoglycemia.

lumbar puncture

done to obtain CSF, which is sent for a culture and sensitivity and Gram stain, in order to identify intracranial infections.

left hemisphere

e is responsible for speech, problem solving, reasoning, and calculations.

Positron emission tomography (PET)

identifies the amount of tissue damage after a CVA.

CT scan

identifies the size and location of the CVA. It is useful to differentiate between an infarction and hemorrhage.

reflex i

involuntary motor response to a stimulus.

Cerebrospinal fluid (CSF)

is found in the subarachnoid space between the arachnoid and the pia mater.

Lumbar puncture

is used to obtain CSF for examination. Blood in the CSF indicates a hemorrhagic CVA

Diagnostic tests - Serum sodium and osmolarity

measured because low sodium levels, or increased or decreased osmolarity, may cause an altered LOC.

Withdrawal reflexes

occur when a person expects pain and automatically withdraws the threatened body part.

Age-related Changes in the Eye and vision

presbyopia. ectropion entropion Tears are decreased, so the eyes may feel dry and scratchy.

The nervous system

regulates and integrates all body functions, muscle movements, senses, mental abilities, and emotions. Alterations in the nervous system can affect human functions such as cardiac and respiratory function, activity, comfort, and elimination. consists of the brain, spinal cord, and peripheral nerves.

Superficial reflexes

result from gently stimulating the skin. For example, the plantar reflex is elic- ited by stroking the sole of the foot. The normal response is to curl the toes downward.

Common reflexes

stretch, deep tendon, with- drawal, and superficial.

Doppler ultrasound

studies evaluate the flow of blood through the carotid arteries and identify if a vessel is partially or completely occluded.

In the older adult

the brain atrophies, causing slower move- ment and reflexes, as well as a degree of forgetfulness. How- ever, significant short- and long-term memory loss, mental status changes, altered coordination, loss of motor skills, and altered speech signal a need for further assessment. The patient may have difficulty changing position or standing up without assistance. This may be accompanied by dizziness, which is the result of anemia, ear infection, eye problems, stroke, or drug toxicity. These changes are often related to common chronic diseases that develop in older adults. Decreased corneal sensation and tear secretion Constriction of the pupil Decreased elasticity and increased density of the lens Loss of rods at the periphery of the retina Loss of fat and subcutaneous tissue around the eyes

Apraxia:

the inability to carry out a familiar routine (e.g., brushing teeth or combing hair), even when paralysis is not present.

Agnosia:

the inability to recognize a familiar object such as a toothbrush.

Cerebrum

the largest area of the brain and is divided into a right and left hemisphere.

Diagnostic tests - Arterial blood gases

used to rule out low oxygen or high carbon dioxide levels, another cause of altered LOC.

ptosis

(drooping eyelids)

The client with Parkinson's disease is being taught about taking carbidopalevodopa (Sinemet). What teaching points should the nurse emphasize? Select all that apply. a. Report the "on-off" effect b. Change position slowly c. Report blurred vision or a rash d. Avoid taking medication with meals e. Monitor the color of urine f. Increase fluid intake

2, 3, 6, 1, 5, 4 Rationale: Loosen the gown and turn client on his side. If on floor, place pillow under head and clear area of objects that could cause injury. Provide supplemental oxygen. Pad the side rails as soon as possible.

Patients with suspected stroke must receive immediate treatment within __________ hours to preserve as much brain function as possible.

3

Which client would the nurse identify as being most at risk for experiencing a CVA? A A 55-year-old African American male. B An 84-year-old Japanese female. C A 67-year-old Caucasian male. D A 39-year-old pregnant female

A A 55-year-old African American male. Africana Americans have twice the rate of CVA's as Caucasians; males are more likely to have strokes than females except in advanced years. Oriental's have a lower risk, possibly due to their high omega-3 fatty acids. Pregnancy is a minimal risk factor for CVA.

Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene? A Placing the client on the back with a small pillow under the head. B Keeping portable suctioning equipment at the bedside. C Opening the client's mouth with a padded tongue blade. D Cleaning the client's mouth and teeth with a toothbrush.

A Placing the client on the back with a small pillow under the head. A helpless client should be positioned on the side, not on the back. This lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction, so having suction equipment at the bedside is necessary. Padded tongue blades are safe to use. A toothbrush is appropriate to use.

A client has come to the physician to seek help for a decrease in hearing. What tests are likely to be performed for this client? a. A Romberg and Sway test b. A Babinski and Stimulation test c. A Rinne and Weber test d. A Rosenbaum and LOC test

A Rinne and Weber test. Rationale: More than 10% of adults, especially those over age 75, experience hearing deficits. Two diagnostic hearing tests, Rinne and Weber, are useful to identify the extent of hearing loss. The Rosenbaum test is used for close vision reading. The Babinski is a test for reflex action of the foot testing for a CNS deficit. The Romberg also tests for CNS deficit.

The nurse is caring for a client with myasthenia gravis. When planning the client's care, what action is most important for the nurse to implement? a. Note any complaints by the client of changes in vision b. Administer medications on a strict time schedule c. Perform the client's care quickly because of tiring easily d. Monitor for facial muscle weakness

Administer medications on a strict time schedule. Outcome 6. Rationale: Clients with dysphagia may not be able to swallow the medication unless it is taken exactly on time. Doses taken too late may cause myasthenic crisis. Notes about changes in vision are not the priority; providing medication on time is. The nurse must prevent client tiring, but this is not the most important action of those listed. Monitoring for facial muscle weakness is not as important as ensuring that medications are given on time to prevent myasthenic crisis.

Once a CVA has occurred, immediate medical attention is needed.

At first, the medical team concentrates on diagnosing the type of CVA and preserv- ing life. Drugs are ordered to reduce IICP and prevent neu- rologic deficits. After the acute phase, care focuses on the patient's rehabilitation.

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? A Cholesterol level B Pupil size and pupillary response C Bowel sounds D Echocardiogram

B Pupil size and pupillary response It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. Cholesterol level is an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but is not a priority in the first 24 hours. An echocardiogram is not needed for the client with a thrombotic stroke.

The nurse is caring for a client with multiple sclerosis. Which one of these medications should the nurse expect to give if the client develops urinary frequency? a. Amantadine (Symmetrel) b. Dexamethasone (Decadron) c. Dantrolene (Dantrium) d. Propantheline (Pro-Banthine)

Bacterial meningitis. Rationale: Meningitis is an inflammation of the spinal cord and meninges. It is usually secondary to an upper respiratory infection. Encephalitis is caused by a virus in most cases, not by bacteria. Brain abscesses occur from middle ear infection. A subdural hematoma is a collection of blood underneath the dura mater, not an infection of the meninges.

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? A A blood glucose level of 480 mg/dl. B A right-sided carotid bruit. C A blood pressure of 220/120 mmHg. D The presence of bronchogenic carcinoma

C A blood pressure of 220/120 mmHg. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a rupture blood vessel in the cranium. A bruit in the carotid artery would predispose a client to an embolic or ischemic stroke. High blood glucose levels could predispose a patient to ischemic stroke, but not hemorrhagic. Cancer is not a precursor to stroke.

During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's: A Pulse B Respirations C Blood pressure D Temperature

C Blood pressure Controlling the blood pressure is critical because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Blood pressure should be maintained according to physician and is specific to the client's ischemic tissue needs and risks of bleeding from treatment. Other vital signs are monitored, but the priority is blood pressure.

A 78 year old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? A Prepare to administer recombinant tissue plasminogen activator (rt-PA). B Discuss the precipitating factors that caused the symptoms. C Schedule for A STAT computer tomography (CT) scan of the head. D Notify the speech pathologist for an emergency consult.

C Schedule for A STAT computer tomography (CT) scan of the head. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment, because only an ischemic stroke can use rt-PA. This would make (1) not the priority since if a stroke was determined to be hemorrhagic, rt-PA is contraindicated. Discuss the precipitating factors for teaching would not be a priority and slurred speech would as indicate interference for teaching. Referring the client for speech therapy would be an intervention after the CVA emergency treatment is administered according to protocol.

The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? A The assistant places a gait belt around the client's waist prior to ambulating. B The assistant places the client on the back with the client's head to the side. C The assistant places her hand under the client's right axilla to help him/her move up in bed. D The assistant praises the client for attempting to perform ADL's independently.

C The assistant places her hand under the client's right axilla to help him/her move up in bed. This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; as always use a lift sheet for the client and nurse safety. All the other actions are appropriate.

A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment? A Current medications. B Complete physical and history. C Time of onset of current stroke. D Upcoming surgical procedures.

C Time of onset of current stroke. The time of onset of a stroke to t-PA administration is critical. Administration within 3 hours has better outcomes. A complete history is not possible in emergency care. Upcoming surgical procedures will need to be delay if t-PA is administered. Current medications are relevant, but onset of current stroke takes priority.

A client was accidentally struck in the head by a baseball bat. Which condition should the nurse anticipate as a serious complication? a. Clear fluid draining from the ears b. Large hematoma at the impact site c. Headache d. Complaints of dizziness

Clear fluid draining from the ears. Rationale: Blunt trauma may cause a contusion of the brain. If the skull is fractured, there may be leakage of cerebrospinal fluid into the ears or nose. Infection is a serious complication of brain injury. Hematomas commonly develop from blood leaking underneath the skin at the site of injury; the serious complication would be leakage of CSF from the ears. Headaches are commonly seen after a blow to the head and are not a serious complication like leakage of CSF from the ear. Dizziness is commonly seen after a blow to the head and is not a serious complication.

When the client has difficulty maintaining balance, what cranial nerve is involved? a. Cranial nerve III b. Cranial nerve V c. Cranial nerve VIII d. Cranial nerve XI

Cranial nerve VIII Rationale: Cranial nerve VIII (vestibulocochlear) is responsible for hearing and equilibrium. Cranial nerve III (oculomotor) controls pupil constriction and eye movement; V (trigeminal) controls chewing and scalp sensations; and XI (accessory) controls neck and shoulder movement.

The nurse is caring for a client who has just had a myelogram (water-soluble dye was used). What teaching point should the nurse emphasize to the client? a. Avoid coughing or sneezing b. Stay flat in bed for 8 to 12 hours c. Drink plenty of fluids d. Avoid eating for 6 hours

Drink plenty of fluids. Rationale: The client should have a fluid intake of 2,400 to 3,000 mL in 24 hours to reduce the possibility of headache. There is no need to avoid coughing or sneezing after a myelogram. The client does not need to stay flat in bed for 8-12 hours after a myelogram. The client does not need to avoid eating after a myelogram.

Electroencephalogram (EEG)

Electrodes are placed on the scalp to record brain electrical activity. Done to diagnose epilepsy, brain tumor, abscess, or hematoma, and brain death. *Nursing Implications* Noninvasive procedure that does not cause electric shock. Assist the patient to wash electrode paste out of hair.

When caring for the client with a herniated lumbar disk, which intervention should the nurse implement? a. Encourage the client to sit in a comfortable chair b. Elevate the client's head and place a small pillow under the knees c. Place the client in a low Fowlers position d. Turn the client once a shift

Elevate the client's head and place a small pillow under the knees. Outcome 5. Rationale: Elevate the client's head and place a small pillow under the knees for a herniated lumbar disk to decrease intervertebral pressure. Sitting in a chair would increase intervertebralpressure. Movement is not contradicted, but elevating the client's head and placing a small pillow under the knees for a herniated lumbar disk will decrease intervertebral pressure. Clients need to be turned more often than once in 8 hours.

Fluorescein stain

Fluorescein dye is injected onto the cornea, and the cornea is viewed with a slit lamp. The green staining allows identification of corneal ulceration or abrasion. *Nursing Implications* Explain that the dye may sting slightly when inserted, and the staining will wash away with tears.

Caloric testing

In caloric testing, cold or warm water is injected into the semicircular canals. The patient is observed for nystagmus, nausea, vomiting, falling, or vertigo, indicating labyrinth disease. *Nursing Implications* Ensure patient safety by observing for vomiting and assisting as necessary to prevent aspiration.

The nurse is caring for a client who has sustained a spinal cord injury above the sixth cervical vertebrae. Which of the following stimuli could trigger autonomic dysreflexia? a. Bladder distention b. A headache c. Sneezing d. Cold feet

Ineffective Breathing Pattern Rationale: SCI at C4 have a high risk for breathing problems that must be addressed first. Impaired Urinary Elimination will be addressed later, but is not the highest priority on admission. Low Self-Esteem may become an issue later and will be addressed. Risk for Injury: Stress Ulcers will be addressed later, but is not the highest priority on admission.

Cerebral angiogram

Invasive procedure that combines x-ray and fluoroscopy (a radiographic image displayed on a screen) with injection of contrast medium into the vessel to illuminate blood flow through the vessel and evaluate its patency. Used to detect an aneurysm, brain tumor, and stroke. *Nursing Implications* Withhold fluids and food for 8 hours before test. Explain that the patient will have hot flush of head and neck when contrast medium is injected. *clinicalAlErT* Closely monitor neurologic and vital signs; maintain pressure dressing and ice to the injection site. Immediately report bleeding or swelling to the charge nurse and physician.

A client experienced a blow to the right frontal region of the head. If the client begins to develop increased intracranial pressure, which manifestation should the nurse see first? a. Decreased heart rate b. Sluggish response by pupils to light c. Irritability d. Projectile vomiting

Irritability. Rationale: The earliest sign of increased intracranial pressure is level of consciousness. Irritability, personality changes, restlessness, and disorientation are early manifestations of ICP. Decreased heart rate is seen in a later stage of IICP. Slow pupil response is seen in a late, not early, stage of IICP. Projectile vomiting is seen during later, not early, stages of IICP.

After a lumbar puncture, which nursing action should the nurse implement? a. Remind the client not to move legs after the procedure b. Monitor the puncture site for CSF leakage c. Have the client empty his bladder d. Limit the client's fluid intake 4. What teaching point should the nurse emphasize to a client taking phenytoin (Dilantin) on a daily basis? a. Check urine for brownish color b. Report fatigue and weakness c. Do not take with food d. Brush and floss daily

Monitor the puncture site for CSF leakage. Rationale: It is most important to monitor for CSF leak and hematoma formation. Client is kept flat afterward for 4 to 24 hours but can move the legs. Fluids are increased, not limited. Client should empty bladder before the procedure; not necessary afterward.

Electromyogram (EMG)

Needles are inserted into skeletal muscles (as on the legs) to record electrical activity. Used to diagnose such disorders as multiple sclerosis, myasthenia gravis, and spinal cord injury or disease. *Nursing Implications* Explain that there is slight discomfort when the needles are inserted. Tell the patient to avoid caffeine or nicotine for 3 hours before the test.

The elderly client has had a recent stroke causing drooling and the inability to raise the eyebrow on one side. The nurse knows that which two cranial nerves have been affected? a. Nerves I and IV b. Nerves V and VIII c. Nerves III and VII d. Nerves II and IX

Nerves III and VII. Rationale: Cranial nerve III is the Oculomotor nerve controlling pupil constriction, eyeball movement and raising of upper eyelid, while cranial nerve VII is the Facial nerve controlling movement of facial muscles, secretions from lacrimal and salivary glands and taste in anterior two-thirds of tongue,

The LPN/LVN must add a thickener to all liquids given to a client with dysphagia. The nurse knows that what cranial nerves are involved? a. Nerves IX and X b. Nerves IV and II c. Nerves I and VI d. Nerves V and VI

Nerves IX and X Rationale: Cranial nerve IX is the Glossopharyngeal controlling swallowing, gag reflex, sensation of pharynx and tongue, taste in posterior one-third of tongue, and secretions of parotid gland while Cranial nerve X is the Vagus nerve which controls swallowing.

After a craniotomy for removal of a brain tumor located in the occipital lobe, what nursing intervention should the nurse implement? a. Place the client in a side-lying position b. Monitor for signs of cranial nerve impairment c. Give morphine for headache d. Monitor vital signs every four hours

Place in a side-lying position. Rationale: Removing a tumor from the occipital lobe requires the client to be placed in a sidelying position. Assessing for cranial nerve impairment is important after carotid artery surgery. Morphine is never given after a craniotomy, as it could mask signs of neurologic deterioration. Only Tylenol or codeine is given for headache. Vital signs must be monitored every 1-2 hours.

1. Which of the following visual changes should the nurse expect the older adult client to report? a. Increased tear secretion b. Reduced ability to differentiate blue and green colors c. Reduced vision during daylight hours d. Difficulty focusing on objects in the distance

Reduced ability to differentiate blue and green colors. Rationale: Older adults report reduced ability to discriminate between blue and green colors. They experience less tear secretion. Their vision is reduced at night. They have difficulty focusing on near objects, not far objects.

VIII Vestibulocochlear

Sense of hearing and equilibrium

IX Glossopharyngeal

Swallowing Gag reflex Sensation of pharynx and tongue Taste in posterior one-third of tongue Secretions of parotid gland

A client is admitted with a spinal cord injury at C4. Which of the following nursing diagnoses is the highest priority for this client? a. Ineffective Breathing Pattern b. Impaired Urinary Elimination c. Low Self-Esteem d. Risk for Injury: Stress Ulcers

Teach client how to reduce frequency of attacks Rationale: Client education is a priority because most headaches are treatable at home. Helping a client understand what causes the migraines may help reduce the number of attacks. Diaries may be useful, but the priority is teaching how to reduce frequency. Comfort measures are important, but the priority is teaching how to reduce frequency of attacks. Stress reduction classes are also important, but the priority is teaching how to reduce frequency of attacks.