Wk 12- Neurological System

Which instruction would the nurse give to a patient while performing the Romberg test?

"Stand with feet together and eyes open then closed." A positive Romberg sign is the loss of balance that occurs when closing the eyes. 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. 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.

While assessing the deep tendon reflexes in a patient, the nurse finds that the responses are very brisk and hyperactive, with clonus. Which grade should the nurse enter in the patient's medical record?

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.

What is the major function of the glossopharyngeal nerve?

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.

The nurse observes a student nurse who is assessing pain perception in a patient. Which action of the student nurse needs correction?

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.

How would an adult patient normally respond to the plantar reflex?

By 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.

While assessing neurologic function, the nurse touches a cotton wisp on the patient's forehead, cheeks, and chin. Which cranial nerve is the nurse testing?

CN V The nurse is testing the sensory function of cranial nerve V (or the trigeminal nerve). 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.

Which cranial nerve injury may cause anosmia in the patient?

Cranial 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.

The nurse asks the patient to close the eyes and then places a paper clip on the patient's palm. The patient is asked to recognize the object. Which test is the nurse performing?

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.

How would a nurse test a patient's superficial reflex?

Test the reactions elicited by stroking the skin. Superficial reflexes are also called cutaneous reflexes. Here, the sensory receptors are in the skin rather than in the muscles. The motor response is a localized muscle contraction. If the skin of the patient is stroked with a reflex hammer, ipsilateral contraction of the skin occurs. Deep tendon reflexes are also known as the stretch reflex. Measurement of the stretch reflex reveals the intactness of the reflex arc at specific spinal levels. The nurse feels and sees rapid, rhythmic contractions of the calf muscles and the movement of the foot to test for clonus. To test the cremasteric reflex of the first two lumbar vertebrae, the nurse notes the elevation of the ipsilateral testicle in a male patient.