PCN 2 Exam- Chp.60: Assessment of Neuro Function and Diagnostic Tests - Notes and PrepU questions

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? "Lying on your left side will be fine during the procedure." "There's no other option but to assume the knee-chest position." "Although the required position may not be comfortable, it will make the procedure safer and easier to perform." "I'll report your concerns to the physician."

"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 GABA Dopamine Serotonin

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.

A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first? Maintain the client NPO for 6 hours before the test. Obtain a blood sample to evaluate BUN and creatinine concentrations. Assess the client for medication allergies. Obtain two large-bore IV lines.

Assess the client for medication allergies. 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 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? Cease function and shunt blood to the heart and lungs. Convert glycogen to glucose for immediate use. Produce a toxic byproduct in relation to stress. Maintain a basal rate of functioning.

Convert glycogen to glucose for immediate use. 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.

Age-related changes in the neurologic system must be carefully assessed. Which of the following changes does the nurse expect to find in some degree depending on the patient's age and medical condition? Select all that apply. Hyper-reactive deep tendon reflexes Decreased muscle mass Increased sensitivity to heat and cold Stage IV sleep is prolonged Increased sensitivity of taste buds Reduced papillary responses

Decreased muscle mass Increased sensitivity to heat and cold Stage IV sleep is prolonged Reduced papillary responses

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

Have the patient lie flat for 6 hours. Post-lumbar puncture headache may be avoided if a small-gauge needle is used and if the patient remains prone after the procedure. When more than 20 mL of CSF is removed, the patient is positioned supine for 6 hours

A patient has been diagnosed with a deficiency of the major neurotransmitter acetylcholine. Based on this information, the nurse knows to assess the patient for complications associated with: Fine movements. Sleep patterns. Heart rate and rhythm. Emotional balance.

Heart rate and rhythm. Acetylcholine is a major transmitter of the parasympathetic nervous system and stimulates the vagal nerve to slow the heart rate.

Ataxia

Inability to coordinate voluntary muscle movement, causing difficulty in walking

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

Position the client flat as directed. A client who has undergone a lumbar puncture should be positioned flat and given adequate fluids. These measures help restore the cerebrospinal fluid volume extracted from the client and are priority activities. The client is administered antihistamines to manage any allergic reactions that may occur from the test. The nurse should assess the LOC or the pupil response of the client after a lumbar puncture. Parenteral administration of caffeine sodium benzoate may offset cerebral vasodilation.

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? milligram electroencephalogram echoencephalography cerebral angiography

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.

flaccidity

when the client has no motor response to stimuli

A critical care nurse is documenting the assessment of a client. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. This means that the client: has an abnormal posture response to stimuli. is not responding to stimuli. is hyperresponsive on the left. is hyporesponsive on the left.

is not responding to stimuli. Flaccidity is when the client has no motor response to stimuli. Flaccidity is a motor assessment.

The nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response? observing the reaction of pupils to light observing the client's response to painful stimulus using the Romberg test assessing the client's sensitivity to temperature, touch, and pain

observing the client's response to painful stimulus -The nurse evaluates motor response in a comatose or unconscious client by administering a painful stimulus. This action helps determine if the client makes an appropriate response by reaching toward or withdrawing from the stimulus. The Romberg test is used to assess equilibrium in a noncomatose client. Pupils are examined for their reaction to light to assess sensitivity in the third cranial (oculomotor) nerve. Sensitivity to temperature, touch, and pain is a test to assess the sensory function of the client and not motor response.

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? Administer antihistamines according to the physician's prescription Keep the room brightly lit and play soothing music in the background Help the client take a brisk walk around the testing area Encourage the client to drink liberal amounts of fluids

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.