Ch 65 PrepU Assessment of Neurologic Function

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

"Although the required position may not be comfortable, it will make the procedure safer and easier to perform."

The cerebral circulation receives approximately what percentage of the cardiac output?

15%

Which of the following neurotransmitters are deficient in myasthenia gravis? Acetylcholine GABA Dopamine Serotonin

Acetylcholine

A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with:

Body temperature control The body's thermostat is located in the hypothalamus; therefore, injury to that area can cause problems with body temperature control

The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm? A. Myelogram B. Electroencephalogram C. Echoencephalography D. Cerebral angiography

Cerebral angiography The nurse would anticipate a cerebral angiography, which detects distortion of the cerebral arteries and veins

Decorticating posturing indicates

Cerebral dysfunction

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates:

Dysfunction in the brain stem

Alterations in sensation or paralysis indicate

Dysfunction in the spinal column

Ultrasound of structures of the brain

Echoencephalography

Which safety action will the nurse implement for a client receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)?

Ensure that no client care equipment containing metal enters the room where the MRI table is located.

Observing for symmetry when the client performs facial movements tests

Facial nerve

Thinking and reasoning problems are the result of

Injury to the cerebrum

Detects abnormalities of the spinal canal

Myelogram

Lobe contains the primary sensory cortex, which analyzes sensory information and relays interpretation to the thalamus and other cortical areas

Parietal

Sustained increase in tension of a muscle when it is passively lengthened or stretched

Spasticity

A client who has sustained a head injury to the parietal lobe cannot identify a familiar object by touch. The nurse knows that this deficit is which of the following? Visual agnosia Positive Romberg Ataxia Tactile agnosia

Tactile agnosia

Lobe that contains the auditory receptive area

Temporal

A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for:

hypoxia

A client presents to the emergency department status post-seizure. The physician wants to know what the pressure is in the client's head. What test might be ordered on this client?

lumbar puncture

Which term describes the fibrous connective tissues that cover the brain and spinal cord? Meninges Dura mater Arachnoid mater Pia mater

meninges

A patient is treated for a neurologic dysfunction affecting facial expressions. The affected cranial nerve originates in the: cerebral hemisphere. midbrain. pons. medulla.

pons CN V -VIII connect to the brain in the pons. CN VII (facial nerve) affects facial expressions and muscle movements.

During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to: use the pointed end of the reflex hammer when striking the Achilles tendon. support the joint where the tendon is being tested. tap the tendon slowly and softly. hold the reflex hammer tightly.

support the joint where the tendon is being tested.

A patient arrives to have an MRI done in the outpatient department. What information provided by the patient warrants further assessment to prevent complications related to the MRI?

"I am trying to quit smoking and have a patch on." Before the patient enters the room where the MRI is to be performed, all metal objects and credit cards (the magnetic field can erase them) must be removed. This includes medication patches that have a metal backing and metallic lead wires; these can cause burns if not removed

The nurse is preparing a client for a neurological examination by the physician and explains tests the physician will be doing, including the Romberg test. The client asks the purpose of this particular test. The correct reply by the nurse is which of the following? "It is a test for balance." "It is a test for coordination." "It is a test for muscle strength." "It is a test for motor ability."

"It is a test for balance."

A potential complication of a hemorrhagic stroke is interference with the ability of the arachnoid villi to absorb CSF. Therefore, fluid in the ventricles increase beyond the amount that is usually absorbed daily, which is: 150 to 200 mL. 200 to 250 mL. 275 to 325 mL. 350 to 375 mL.

350-375mL 500ml CSF produced a day, all but 125-150 absorbed

Which anatomic part supplies cerebrospinal fluid to the subarachnoid space and down the spinal cord on the dorsal surface? Third ventricle Fourth ventricle Lateral ventricle Arachnoid villus

4th ventricle

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

Acoustic

The nurse is caring for a client with a significant allergy history to various medications and shellfish. Because the client needs to have a diagnostic study with contrast, which medication classification is anticipated?

Antihistamine

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

Ataxia Ataxia is the inability to coordinate voluntary muscle action; tremors (rhythmic, involuntary movements) noted at rest or during movement suggest a problem in the anatomic areas responsible for balance and coordinatio

The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve?

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

The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart? A. CN I B. CN III C. CN II D. CN IV

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

Balance an equilibrium problems are related to

Cerebellar damage

What part of the brain controls and coordinates muscle movement?

Cerebellum

Lower motor neuron lesions cause increased muscle tone. flaccid muscles. no muscle atrophy. hyperactive and abnormal reflexes.

Flaccid muscles Lower motor neuron lesions cause flaccidity, muscle atrophy, decreased muscle tone, and loss of voluntary control. Upper motor neuron lesions cause increased muscle tone. Upper motor neuron lesions cause no muscle atrophy. Upper motor neuron lesions cause hyperactive and abnormal reflexes.

Which cerebral lobes is the largest and controls abstract thought?

Frontal The frontal lobe also controls information storage or memory and motor function

A patient sustained a head injury during a fall and has changes in personality and affect. What part of the brain does the nurse recognize has been affected in this injury?

Frontal lobe

Cranial nerve IX is also known as which of the following? Glossopharyngeal Vagus Spinal accessory Hypoglossal

Glossopharyngeal

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.

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

Which of the following areas of the brain are responsible for temperature regulation? Hypothalamus Thalamus Pons Medulla

Hypothalamus

A patient has expressive speaking aphasia after having a stroke. Which portion of the brain does the nurse know has been affected? Temporal lobe Inferior posterior frontal areas Posterior frontal area Parietal-occipital area

Inferior posterior frontal areas

A client is admitted to an acute care facility for treatment of a brain tumor. When reviewing the chart, the nurse notes that the client's extremity muscle strength is rated 1/5. Which assessment finding should the nurse anticipate? Normal, full muscle strength is present. Muscles move actively against gravity alone. Muscle contraction is palpable and visible. Muscle contraction or movement is undetectable.

Muscle contraction is palpable and visible.

A nurse is completing a neurological assessment and determines that the client has significant visual deficits. A brain tumor is considered. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit? Frontal Parietal Temporal Occipital

Occipital

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

Serotonin

A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in thought content. motor ability. intellectual function. emotional status.

Thought content

Decerebrate posturing indicates damage of the

Upper brain stem

A nurse is performing a neurologic assessment on the client and notes a positive Romberg test. This test for balance is related to which of the following cranial nerves? VIII X III VII

VIII

The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of cranial nerve: A. VI B. XI C. VIII D. II

VIII VIII is the vestibulocochlear or auditory nerve responsible for hearing and balance

Having the client say "ah" tests what nerve

Vagus nerve

When completing a neurologic examination on a client, which question is most essential to evaluate the accuracy of the data? When, if any, was your last narcotic use? Do you have any history of forgetfulness? Have you been diagnosed with any mental health issues? Have you experienced any unusual sensations?

When, if any, was your last narcotic use? When completing a neurologic exam, it is essential to assess the use of morphine, heroin, narcotic, or central nervous system depressant because these affect the results of a neurologic examination. These types of drugs decrease the level of consciousness.

A client is scheduled for standard EEG testing to evaluate a possible seizure disorder. Which nursing intervention should the nurse perform before the procedure? Withhold anticonvulsant medications for 24 to 48 hours before the exam Maintain NPO status for 6 hours before the procedure Sedate the client before the procedure, per orders Instruct the client that a standard EEG takes 2 hours

Withhold anticonvulsant medications for 24 to 48 hours before the exam

A nurse is performing a neurologic assessment on a client. The nurse observes the client's tongue for symmetry, tremors, and strength, and assesses the client's speech. Which cranial nerve is the nurse assessing?

XII Cranial nerve XII, the hypoglossal nerve, controls tongue movements involved in swallowing and speech. The tongue should be midline, symmetrical, and free from tremors and fasciculations. The nurse tests tongue strength by asking the client to push his tongue against his cheek as the nurse applies resistance. To test the client's speech, the nurse may ask him to repeat the sentence, "Round the rugged rock that ragged rascal ran."

Which neurotransmitter inhibits pain transmission?

enkephalin

a patient has an upcoming EMG what should the nurse tell the patient?

expect discomfort

CN responsible for salivation, tearing, taste, and sensation in the ear?

facial VII

A comatose client is being cared for by a critical care nurse who documents that the client responds only to very painful stimuli by fragmentary, delayed reflex withdrawal. The nurse knows that reflexes in the body are centered where? In the pons In the medulla oblongata In the spinal cord In the midbrain

in spinal cord

Upper motor neuron lesions cause? little to no muscle atrophy. decreased muscle tone. flaccid paralysis. absent or decreased reflexes.

little to no muscle atrophy

The anatomy instructor is discussing the central nervous system. A student asks where the cerebral cortex is located. What should the anatomy instructor answer?

located on surface of the cerebrum

A nurse is noting from a client's neurologic assessment findings that the client's motor impulses are interrupted from the brain to the spinal cord. It also appears that the client lacks sensory impulses from the peripheral sensory neurons to the brain. Which area has the deficit? midbrain medulla oblongata pons subarachnoid space

medulla oblongata

Which neurons transmit impulses from the CNS?

motor Neurons are either sensory or motor. Sensory neurons transmit impulses to the CNS; motor neurons transmit impulses from the CNS.

he nurse is caring for a client in the emergency department with a diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the client's face and torso. The nurse would provide further instruction after seeing that the nurse aide: used mild soapy water to clean the face. moved the client's head to clean behind the ears. cleaned the eye area from the inner to outer eye area. cleaned the neck and upper chest area.

moved the client's head to clean behind the ears.

A patient is admitted to a specialty care unit with a diagnosis of an upper motor neuron lesion. The nurse assesses the patient and documents the presence of: Decreased muscle tone. Flaccid muscle paralysis. Muscle spasticity. Absent reflexes.

muscle spasticity

During a neurological assessment examination, the nurse assesses a patient for tactile agnosia. The nurse places a familiar door key in the patient's hand and asks him to identify the object with his eyes closed. The nurse documents his inability to identify the object and notes the affected area of the brain. What is the most likely affected area of the brain?

parietal lobe "Sensory"

A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by: introducing ice water into the external auditory canal. touching the cornea with a wisp of cotton. turning the client's head suddenly while holding the eyelids open. shining a bright light into the pupil.

turning the client's head suddenly while holding the eyelids open.

Records electrical impulses of the brain

Electroencephalogram

The brain stem holds the medulla oblongata. What is the function of the medulla oblongata? A. Controls striated muscle activity in blood vessel walls B. Controls parasympathetic nerve impulses in the PNS C. Transmits sensory impulses from the brain to the spinal cord D. Transmits motor impulses from the brain to the spinal cord

Transmits motor impulses from the brain to the spinal cord The medulla oblongata lies below the pons and transmits motor impulses from the brain to the spinal cord and sensory impulses from peripheral sensory neurons to the brain. The medulla contains vital centers concerned with respiration, heartbeat, and vasomotor activity (the control of smooth muscle activity in blood vessel walls).

A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain? III IV V VI

V The trigeminal nerve (cranial nerve V) innervates the forehead, cheeks, and jaw, so pain in the face elicited when brushing the teeth would most likely involve this nerve.

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

sympathetic nervous system.

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

Assess 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.

Lesions in the temporal lobe may result in which type of agnosia? Agnosia means —> Loss of the ability to identify objects or people A. Auditory B. Visual C. Tactile D. Relationship

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

A patient recently noted difficulty maintaining his balance and controlling fine movements. The nurse explains that the provider will order diagnostic studies for the part of his brain known as the:

Cerebellum The cerebellum is largely responsible for coordination of all movement. It also controls fine movement, balance, position (postural) sense or proprioception (awareness of where each part of the body is), and integration of sensory input.

A nurse is preparing a client for a lumbar puncture. The client has heard about post-lumbar puncture headaches and asks what causes them. The nurse tells the client that these headaches are caused by which of the following? A. Cerebral spinal fluid leakage at the puncture site B. Damage to the spinal cord C. Traumatic puncture D. Not ambulating soon enough after the procedure

Cerebral spinal fluid leakage at the puncture site The headache is caused by cerebral spinal fluid (CSF) leakage at the puncture site. The supply of CSF in the cranium is depleted so that there is not enough to cushion and stabilize the brain. When the client assumes an upright position, tension and stretching of the venous sinuses and pain-sensitive structures occur.

A nurse is working in a neurologist's office. The physician orders a Romberg test. The nurse should have the client:

Close his or her eyes and stand erect

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, the nurse anticipates that the liver will: A. cease function and shunt blood to the heart and lungs. B. convert glycogen to glucose for immediate use. C. produce a toxic byproduct in relation to stress. D. maintain a basal rate of functioning.

Convert glycogen to glucose for immediate use

The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve? Cranial nerve I Cranial nerve V Cranial nerve XI Cranial nerve XII

Cranial nerve XII

If a client has a lower motor neuron lesion, the nurse would expect the client to exhibit A. Decreased muscle tone B. No muscle atrophy C. Muscle spasticity D. Hyperactive reflexes

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

A patient has a deficiency of the neurotransmitter serotonin. The nurse is aware that this deficiency can lead to: A. MS B. Depression C. Seizures D. Parkinsons

Depression Serotonin helps control mood and sleep. A deficiency leads to depression.

Which is a sympathetic effect of the nervous system? A. Decreased respiratory rate B. Decreased blood pressure C. Dilated pupils D. Increased peristalsis

Dilated pupils Dilated pupils are a sympathetic effect of the nervous system, whereas constricted pupils are a parasympathetic effect. Decreased blood pressure is a parasympathetic effect, whereas increased blood pressure is a sympathetic effect. Increased peristalsis is a parasympathetic effect, but decreased peristalsis is a sympathetic effect. Decreased respiratory rate is a parasympathetic effect, and increased respiratory rate is a sympathetic effect.

To evaluate a client's cerebellar function, a nurse should ask: A. "Have you noticed any changes in your muscle strength?" B. "Do you have any difficulty speaking?" C. "Do you have any trouble swallowing food or fluids?" D. "Do you have any problems with balance?"

Do you have any problems with balance To evaluate cerebellar function, the nurse should ask the client about problems with balance and coordination

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

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

Which term refers to a method of recording, in graphic form, the electrical activity of a MUSCLE?

ElectroMYOgraphy

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? A. Administer antihistamines according to the physician's prescription B. Keep the room brightly lit and play soothing music in the background C. Help the client take a brisk walk around the testing area D. 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.

After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an: A. evaluation of the corneal reflex response. B. examination of the fundus of the eye. C. assessment of the client's gait. D. evaluation of bowel and bladder functions.

Evaluation of the corneal reflex response During an acute crisis, the nurse should check the corneal reflex response to rapidly assess brain stem function. Other components of the brief initial neurologic assessment usually include level of consciousness, pupillary response, and motor response in the arms and legs. If appropriate and if time permits, the nurse also may assess sensory responses of the arms and legs. Emergency assessment doesn't include fundus examination unless the client has sustained direct eye trauma. The client shouldn't be moved unnecessarily until the extent of injuries is known, making gait evaluation impossible. Bowel and bladder functions aren't vital, so the nurse should delay their assessment.

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.

A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position? Head of the bed elevated 45 degrees Prone Supine with feet raised Supine with the head lower than the trunk

Head of the bed elevated 45 degrees After a myelogram, positioning depends on the dye injected. When a water-soluble dye such as metrizamide is injected, the head of the bed is elevated to a 45-degree angle to slow the upward dispersion of the dye. The prone and supine positions are contraindicated when a water-soluble contrast dye is used. The client should be positioned supine with the head lower than the trunk after an air-contrast study.

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:

Is not responding to stimuli

A nurse is discussing a lumbar puncture with a nursing student who observed the procedure. The student noticed that the cerebrospinal fluid was blood tinged and asks what that means. The correct reply is which of the following? A. It can mean a traumatic puncture or a subarachnoid bleed B. It can mean a bleed around the hypothalamus or damage from the needle C. It can mean the spinal cord was damaged or a traumatic puncture D. It can mean a subarachnoid bleed or damage o the spinal cord

It can mean a traumatic puncture or a subarachnoid bleed The needle is inserted below the level of the spinal cord, which prevents damage to the cord. The cerebral spinal fluid (CSF) should be clear and colorless. Pink or bloody CSF may indicate a subarachnoid bleed or local trauma from the puncture. The hypothalamus is located deep inside the brain and does not affect the color of the CSF.

What is the function of cerebrospinal fluid (CSF) A. It cushions the brain and spinal cord. B. It acts as an insulator to maintain a constant spinal fluid temperature. C. It acts as a barrier to bacteria. D It produces cerebral neurotransmitters.

It cushions the brain and spinal cord CSF is produced primarily in the lateral ventricles of the brain. It acts as a shock absorber and cushions the spinal cord and brain against injury caused by sudden or extreme movement. CSF also functions in the removal of waste products from cerebral tissue.

The nurse is caring for a client who is to have a lumbar puncture. What are the lowest vertebrae that contain the spinal cord? coccyx second lumbar vertebrae eleventh thoracic vertebrae fifth lumbar vertebrae

L2 The spinal cord ends between the first and second lumbar vertebrae.

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure? Prone, with the head turned to the right Supine, with the knees raised toward the chest Lateral recumbent, with thighs flexed Lateral, with right leg flexed

Lateral recumbent, with thighs flexed

Which of the following is an age-related change in the nervous system? A. Loss of neurons in the brain B. More efficient temperature regulation C. Increased myelin D. Increased cerebral blood flow

Loss of neurons in the brain Structural changes include loss of neurons in the brain, reduced cerebral blood flow, less efficient temperature regulation, and decreased myelin, resulting in decreased nerve conduction in some nerves.

An 83-year-old woman suffers a stroke at home and is hospitalized for treatment and management. Which of the following diagnostic procedures would be best to visualize the extent of damage? Magnetic resonance angiography (MRA) Diffusion-weighted imaging (DWI) Computed tomography (CT) Magnetic resonance imaging (MRI)

MRA An MRA allows separate visualization of the cerebral vasculature and can be used in place of an MRI.

The nurse is caring for a client after lumbar puncture. The client reports a severe headache. Which actions should the nurse complete? Select all that apply. Maintain the client on bed rest. Administer fluids to the client. Position the client in the supine position. Prepare for an epidural blood patch. Administer analgesic medication.

Maintain the client on bed rest. Administer fluids to the client. Administer analgesic medication. When the client assumes an upright position, tension and stretching of the venous sinuses and pain-sensitive structures occur. A postpuncture headache is usually managed by bed rest, analgesic agents, and hydration. Post-lumbar puncture headache may be avoided if a small-gauge needle is used and if the client remains prone after the procedure. When more than 20 mL of cerebrospinal fluid is removed, the client is positioned supine for 6 hours.

The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly? A. Moving the head toward both sides B. Lightly tapping the lower portion of the neck to detect sensation C. Moving the head and chin toward the chest D. Gently pressing the bones on the neck

Moving the head and chin toward the chest The neck is examined for stiffness or abnormal position. The presence of rigidity is assessed by moving the head and chin toward the chest. The nurse should not maneuver the neck if a head or neck injury is suspected or known. The neck should also not be maneuvered if trauma to any part of the body is evident. Moving the head toward the sides or pressing the bones on the neck will not help assess for neck rigidity correctly. While assessing for neck rigidity, sensation at the neck area is not to be assessed.

Which lobe of the brain is responsible for spatial relationships?

Parietal The parietal lobe is essential to a person's awareness of body position in space, size and shape discrimination, and right-left orientation.

Which of the following is a disorder due to a lesion in the basal ganglia? Parkinson's disease Guillain-Barré Myasthenia gravis Multiple sclerosis

Parkinsons

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? A. Administer antihistamines to the client. B. Provide adequate caffeine-rich drinks to the client. C. Leave the client to rest and do not perform any assessments. D. Position the client flat for at least 3 hours.

Position the client flat for at least 3 hours A client who has undergone a lumbar puncture should be positioned flat for at least 3 hours 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.

The nurse has completed evaluating the client's cranial nerves. The nurse documents impairment of the right cervical nerves (CN IX and CN X). Based on these findings, the nurse should instruct the client to A. have their spouse bring in the client's glasses. B. refrain from eating or drinking for now. C. use the walker when walking. D. wear any hearing aids while in the hospital.

Refrain from wasting or drinking for now Significant findings of CN IX (glossopharyngeal) include difficulty swallowing (dysphagia) and impaired taste, and significant findings of CN X (vagus) include weak or absent gag reflex, difficulty swallowing, aspiration, hoarseness, and slurred speech (dysarthria). Based on these findings, the nurse should instruct the client to refrain from eating and drinking and should contact the health care provider. The other instructions are associated with abnormalities of CN II (optic) and CN VIII (acoustic).

A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult slowing transmission of the motor neurons, the nurse would anticipate a delayed reaction in: A. response due to interrupted impulses from the central nervous system B. processing information transferred from the environment. C. cognitive ability to understand relayed information. D. identification of information due to slowed passages of information to brain.

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

A patient has been diagnosed with damage to Broca's area of the left frontal lobe. To document the extent of damage, the nurse would assess the patient's: Speech. Vision. Hearing. Balance.

Speech

A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following? A. The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid B. The blood will replace the cerebral spinal fluid that has leaked out C. The blood an repair damage to the spinal cord that occurred with the procedure D. The blood provides moisture at the site, which encourages healing

The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid Loss of CSF causes the headache. Occasionally, if the headache persists, the epidural blood patch technique may be used. Blood is withdrawn from the antecubital vein and injected into the site of the previous puncture. The rationale is that the blood will act as a plug to seal the hole in the dura and prevent further loss of CSF. The blood is not put into the subarachnoid space. The needle is inserted below the level of the spinal cord, which prevents damage to the cord. It is not a lack of moisture that prevents healing; it is more related to the size of the needle used for the puncture.

The nurse is performing a neurological assessment of a client who has sustained damage to the frontal cortex. Which of the following deficits will the nurse look for during assessment? A The inability to tell how a mouse and a cat are alike B The inability to maintain steady balance for the Romberg test C Absence of movement below the waist D Intentional tremors

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

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

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

The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply. Unequal pupils Pupil reaction quick Pinpoint pupils Absence of pupillary response Pupil reacts to light

Unequal pupils Pinpoint pupils Absence of pupillary response

Which cranial nerve is responsible for facial sensation AND CORNEAL reflex?

V trigeminal also responsible for mastication

The nurse is assessing the client's mental status . Which question will the nurse include in the assessment? A. Are you having any hallucinations now B. Can you write your name on this piece of paper C. Who is the president of the US D. Can you count backward from 100

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

rapid, jerky, involuntary, purposeless movements of the extremities

chorea