Chapter 55 Assessment of Nervous System

b. carries impulses to the nerve cell body

What is the function of the dendrite? a. a gap in the peripheral nerve axons b. carries impulses to the nerve cell body c. carries impulses from the nerve cell body d. may occur with damage to the peripheral axons

c, e, f

What methods are used to assess the facial (CN VII) nerve? (select all that apply) a. gag reflex b. confrontation c. corneal (blink) reflex test d. light touch to the face e. smile, frown, and close eyes f. salt and sugar discrimination

d. position the patient in a lateral recumbent position with the hips, knees, and neck flexed.

What should the nurse do to prepare a patient for a lumbar puncture? a. sedate the patient with medication b. withhold medications containing caffeine for 8 hours c. have tha patient sit on the side of the bed, leaning on a padded over-the-bed table d. position the patient in a lateral recumbent position with the hips, knees, and neck flexed.

D. instruct the patient that she or he may experience pain during the study. (Electromyography (EMG) is used to assess electrical activity associated with nerves and skeletal muscles. Activity is recorded by insertion of needle electrodes to detect muscle and peripheral nerve disease. The nurse should inform the patient that pain and discomfort are associated with insertion of needles. There is no risk of electric shock with this procedure.)

The nurse is caring for a patient with peripheral neuropathy who is going to have EMG studies tomorrow morning. The nurse should: A. ensure the patient has an empty bladder. B. instruct the patient about the risk of electric shock. C. ensure the patient has no metallic jewelry or metal fragments. D. instruct the patient that she or he may experience pain during the study.

a. Ask the patient a question such as, "Who were the last three presidents?" (Cognition is one component of the mental status examination to determine cerebral functioning. Cognition is assessed by determining orientation, memory, general knowledge, insight, judgment, problem solving, and calculation. A question often used to determine cognition for adults living in the United States is, "Who were the last three presidents?" General appearance and behavior are additional components and include level of consciousness, body posture, and facial expressions. Mood and affect are assessed by observing for agitation, anger, or depression. Cerebellar function is determined by assessing balance and coordination, and may include testing rapid alternating movements of the upper and lower extremities.)

The nurse is completing a health assessment for a newly admitted patient. Which assessment should the nurse perform to determine the cognitive function of the patient? a. Ask the patient a question such as, "Who were the last three presidents?" b. Determine the level of consciousness, body posture, and facial expressions. c. Observe for signs of agitation, anger, or depression during the health check. d. Request that the patient mimic rapid alternating movements with both hands.

c. The pain that occurs is from the insertion of the needles. (With an EMG, pain may occur when needles are inserted to record the electrical activity of nerve and skeletal muscle. The patient is not tilted on a table during a myelogram. The electroencephalogram is noninvasive without a danger of electric shock. The magnetoencephalogram is done with a passive sensor that does not make contact with the patient.)

The nurse is preparing the patient for an electromyogram (EMG). What should the nurse include in teaching the patient before the test? a. The patient will be tilted on a table during the test. b. It is noninvasive, and there is no risk of electric shock. c. The pain that occurs is from the insertion of the needles. d. The passive sensor does not make contact with the patient.

b. Falx cerebri

When the patient has a rapidly growing tumor, what slows the expansion of the cerebral brain tissue into the adjacent hemisphere? a. ventricles b. Falx cerebri c. arachnoid layer d. Tentorium cerebella

b. touch, deep pressure, vibration, and position sense

A patient has a lesion involving the fasciculus graclis and fasciculus cuneatus of the spinal cord. What should the nurse expect the patient to experience loss of? a. pain and temperature sensations b. touch, deep pressure, vibration, and position sense c. subconscious information about body position and muscle tension d. voluntary muscle control from the cerebral cortex to the peripheral nerves

a. Ensure that CT scan is performed prior to lumbar puncture

A patient is admitted with a headache, fever, and general malaise. The HCP has asked that the patient be prepared for a lumbar puncture. What is a priority nursing action to avoid complications? a. Ensure that CT scan is performed prior to lumbar puncture b. Assess laboratory results for changes in the white cell count c. Provide acetaminophen for the headache and fever before the procedure. d. Administer antibiotics before the procedure to treat the potential meningitis

d. Altered sense of smell (Using a transsphenoidal approach to remove the pituitary gland includes a risk of damage to the olfactory cranial nerve because the cell bodies of the olfactory nerve are located in the nasal epithelium. With damage to this nerve, the sense of smell would be altered. Increased heart rate, loss of coordination, and impaired swallowing will not be potential deficits from this surgery.)

A patient is having a transsphenoidal hypophysectomy. The nurse should provide preoperative patient teaching about what potential deficit as a result of the surgery? a. Increased heart rate b. Loss of coordination c. Impaired swallowing d. Altered sense of smell

d. Regular insulin 6 units (SQ) (Patients with type 1 diabetes mellitus must have insulin administered the day of the PET if glucose metabolism is the focus of the PET. Diuretics should not be administered before the PET unless a urinary catheter is inserted. The patient must remain still during the procedure (1 to 2 hours). Sedatives and tranquilizers (e.g., alprazolam) should not be administered before a PET of the brain because the patient may need to perform mental activities, and these medications may affect glucose metabolism. Prophylactic antibiotics are not necessary. Patients are NPO before a PET of the brain and should not receive oral medications (alprazolam and ciprofloxacin).)

A patient with heart failure and type 1 diabetes mellitus is scheduled for a positron emission tomogram (PET) of the brain. Which medication prescribed by the health care provider should the nurse expect to administer before the diagnostic study? a. Furosemide 20 mg (IV) b. Alprazolam 0.5 mg (PO) c. Ciprofloxacin 500 mg (PO) d. Regular insulin 6 units (SQ)

c. Assess the patient for allergies to shellfish, iodine, or dyes. (Allergies to shellfish, iodine, or dyes contraindicate the use of contrast media in CT. The patient's immunization history is not a central consideration, and the presence of metal in the body does not preclude the use of CT as a diagnostic tool. The need to assess for allergies supersedes the need for tranquilizers or antiseizure medications in the majority of patients.)

A patient's sudden onset of hemiplegia has necessitated a CT scan of her head. Which action should be the nurse's priority before this diagnostic study? a. Assess the patient's immunization history. b. Screen the patient for any metal parts or a pacemaker. c. Assess the patient for allergies to shellfish, iodine, or dyes. d. Assess the patient's need for tranquilizers or antiseizure medications.

A. constriction of the bronchi. B. dilation of skin blood vessels. C. increased secretion of insulin. E. relaxation of the urinary sphincters. (Stimulation of the parasympathetic nervous system results in constriction of the bronchi, dilation of blood vessels to the skin, increased secretion of insulin, and relaxation of the urinary sphincter. Stimulation of the sympathetic nervous system results in increased blood glucose levels.)

A result of stimulation of the parasympathetic nervous system is (select all that apply): A. constriction of the bronchi. B. dilation of skin blood vessels. C. increased secretion of insulin. D. increased blood glucose levels. E. relaxation of the urinary sphincters.

c. protect the patient from an injury caused by falls

During an assessment of the motor system, the nurse finds that the patient has a staggering gait and an abnormal arm swing. What should the nurse use this information to do? a. assist the patient to cope with the disability b. plan a rehabilitation program for the patient c. protect the patient from an injury caused by falls d. help to establish a diagnosis of cerebellar dysfunction

c. decreased sensation of touch and temperature

During neurologic assessment of the older adult, what should the nurse expect to find? a. absent deep-tendon reflexes b. below-average intelligence score c. decreased sensation of touch and temperature d. decreased frequency of spontaneous awakening

C. temperature perception. (If pain sensation is intact, assessment of temperature sensation may be omitted because both sensations are transmitted by the same ascending pathways.)

During neurologic testing, the patient is able to perceive pain elicited by pinprick. Based on this finding, the nurse may omit testing for: A. position sense. B patellar reflexes. C. temperature perception. D. heel-to-shin movements.

b. left middle cerebral artery (The anterior cerebral artery feeds the medial and anterior portions of the frontal lobes. The anterior portion of the frontal lobe controls higher order processes such as judgment and reasoning.)

During the admitting neurological exam, the nurse determines the patient has speech difficulties as well as weakness of the right arm and lower face. The nurse would expect a CT scan to show pathology in the distribution of the a. basilar artery b. left middle cerebral artery c. right anterior cerebral artery d. left posterior communicating artery

a. headache

Following a lumbar puncture, what should the nurse assess the patient for? a. headache b. lower limb paralysis c. allergic reaction to the dye d. hemorrhage from the puncture site

d. all spinal nerves contain both afferent sensory and efferent motor fibers whereas CNs contain one or the other or both

How do spinal nerves of the PNS differ from cranial nerves? a. only spinal nerves occur in pairs b. CNs affect only the sensory and motor functions of the head and neck c. cell bodies of all CNs are located in the brain whereas cell bodies of spinal nerves are located in the spinal cord. d. all spinal nerves contain both afferent sensory and efferent motor fibers whereas CNs contain one or the other or both

c. Ask the patient to stand with the feet together and eyes closed and observe for balance maintenance. (The Romberg test is an assessment of position sense in which the patient stands with the feet together and then closes his or her eyes while attempting to maintain balance. The other cited tests of neurologic function do not directly assess position sense.)

How should the nurse most accurately assess the position sense of a patient with a recent traumatic brain injury? a. Ask the patient to close his or her eyes and slowly bring the tips of the index fingers together. b. Ask the patient to close his or her eyes and identify the presence of a common object on the forearm. c. Ask the patient to stand with the feet together and eyes closed and observe for balance maintenance. d. Place the two points of a calibrated compass on the tips of the fingers and toes and ask the patient to discriminate the points.

D. oligodendrocytes (Glial cell types include oligodendrocytes, astrocytes, ependymal cells, and microglia, and each has specific functions. Oligodendrocytes are specialized cells that produce the myelin sheath of nerve fibers in the central nervous system (CNS), and they are located primarily in the white matter of the CNS.)

In a patient with a disease that affects the myelin sheath of nerves, such as multiple sclerosis, the glial cells affected are the: A. microglia B. astrocytes C. ependymal cells D. oligodendrocytes

d. glucose level of 30 mg/dl (1.7 mmol/L) (glucose level is low, normal is 40-70 mg/dl. this means that the brain is not getting enough food)

In noting the results of an analysis of CSF, what should the nurse identify as an abnormal finding? a. pH of 7.35 b. clear, colorless appearance c. WBC count of 5/mL (0.005/L) d. glucose level of 30 mg/dl (1.7 mmol/L)

d. the cochlear branch of the acoustic nerve (CN VIII) is damaged

In the neurologic nursing assessment of the patient, he is unable to hear a ticking watch. What neurologic problem could be the cause of this finding? a. the patient is distracted b. the patient is hard of hearing c. the vagus nerve (CN X) is malfunctioning d. the cochlear branch of the acoustic nerve (CN VIII) is damaged

a. A 50-yr-old woman with lethargy from a drug overdose (The glossopharyngeal and vagus nerves innervate the pharynx and are tested by the gag reflex. It is important to assess the gag reflex in patients who have a decreased level of consciousness, brainstem lesion, or disease involving the throat musculature. If the reflex is weak or absent, the patient is in danger of aspirating food or secretions.)

In which patient would it be the most important for the nurse to assess the glossopharyngeal and vagus nerves? a. A 50-yr-old woman with lethargy from a drug overdose b. A 40-yr-old man with a complete lumbar spinal cord injury c. A 60-yr-old man with severe pain from trigeminal neuralgia d. A 30-yr-old woman with a high fever and bacterial meningitis

c. Higher cognitive function abnormalities (Because the frontal lobe is responsible for higher cognitive function, this patient may have difficulty with memory retention, voluntary eye movements, voluntary motor movement, and expressive speech. The lack of reflexes would occur if the patient had problems with the reflex arcs in the spinal cord. Endocrine problems would be evident if the hypothalamus or pituitary gland were affected. Respiratory, vasomotor, and cardiac dysfunction would occur if there were a problem in the medulla.)

The nurse is admitting a patient with a diagnosis of frontal lobe dementia. What functional difficulties should the nurse expect in this patient? a. Lack of reflexes b. Endocrine problems c. Higher cognitive function abnormalities d. Respiratory, vasomotor, and cardiac dysfunction

b. muscle bulk and strength decrease in older adults (Changes associated with aging include decreases in muscle strength & agility in relation to decreased muscle bulk.)

The nurse is assessing the muscle strength of an older adult patient. The nurse knows that the findings cannot be compared with that of younger adults because: a. nutritional status is better in young adults b. muscle bulk and strength decrease in older adults c. muscle strength should be the same for all adults d. most young adults exercise more than older adults

c. Orthostatic hypotension (Older adults are more likely to experience orthostatic hypotension related to altered coordination of neuromuscular activity. Other neurologic changes in older adults include atrophy of taste buds with decreased sense of taste, below-average reflex score (and diminished deep tendon reflexes), and slowed reaction times.)

The nurse is caring for a group of healthy older adults at a community day center. Which neurologic finding associated with aging would the nurse expect to note in older adults? a. Quicker reaction time b. Improved sense of taste c. Orthostatic hypotension d. Hyperactive deep tendon reflexes

a. Assess for drainage or bleeding from the puncture site. (After a lumbar puncture, the nurse should monitor the puncture site for drainage or bleeding. Other assessments include headache intensity, meningeal irritation (nuchal rigidity), signs and symptoms of local trauma (e.g., hematoma, pain), neurologic signs, and vital signs. A lumbar puncture does not affect bowel or bladder function or upper extremity muscle strength. Bed rest until lower extremity movement returns is indicated for the patient after spinal anesthesia.)

The nurse is caring for a patient after a lumbar puncture. Which is a priority action by the nurse? a. Assess for drainage or bleeding from the puncture site. b. Monitor for bladder dysfunction and bowel incontinence. c. Maintain bed rest until lower extremities move normally. d. Check for loss of muscle strength in the upper extremities.

a. Impaired muscle movement (Among the most important descending tracts are the corticobulbar and corticospinal tracts, collectively termed the pyramidal tract. These tracts carry volitional (voluntary) impulses from the cortex to the cranial and peripheral nerves. Dysfunction of the pyramidal tract is likely to manifest as impaired movement because of hypertonicity. Diseases affecting the pyramidal tract do not result in changes in level of consciousness, impaired reflexes, or decreased sensation.)

The nurse is caring for a patient with a neurologic disease that affects the pyramidal tract. What clinical manifestation does the nurse assess in this patient? a. Impaired muscle movement b. Decreased deep tendon reflexes c. Decreased level of consciousness d. Impaired sensation of touch, pain, and temperature

b. Sensory deficit c. Motor function deficit f. Central nervous system changes (Normal changes of aging in the nervous system decrease the sensory function that leads to poor ability to maintain balance and a widened gait. The motor function deficit decreases muscle strength and agility. The central nervous system changes in the brain lead to a diminished kinesthetic sense or position sense. These changes all contribute to an increased risk of falls for the older adult. Memory deficits, normal changes of cranial and spinal nerves, and the reticular activation system do not increase the risk for falls.)

The nurse is caring for an older adult patient. Which normal nervous system changes of aging put this patient at higher risk of falls? SATA a. Memory deficit b. Sensory deficit c. Motor function deficit d. Cranial and spinal nerves e. Reticular activation system f. Central nervous system changes

b. Ask the patient to shrug the shoulders against resistance. (The spinal accessory nerve is tested by asking the patient to shrug the shoulders against resistance and to turn the head to either side against resistance while observing the sternocleidomastoid muscles and the trapezius muscles. Assessing the gag reflex and saying "ah" are used to assess the glossopharyngeal and vagus nerves. Asking the patient to push the tongue to either side against resistance is used to assess the hypoglossal nerve.)

The nurse is performing a neurologic assessment for a patient. When assessing the accessory nerve, what action should the nurse take? a. Assess the gag reflex by stroking the posterior pharynx. b. Ask the patient to shrug the shoulders against resistance. c. Ask the patient to push the tongue to either side against resistance. d. Have the patient say "ah" while visualizing elevation of soft palate.

b. 2/5

The patellar tendon is struck and the leg extends with contraction of the quadriceps. what grade should this response be given? a. 1/5 b. 2/5 c. 3/5 d. 4/5

b. keep the patient flat in the bed for several hours

The patient has just had a myelogram. What should be included in the nursing care for this patient? a. restrict fluids until the patient is ambulatory b. keep the patient flat in the bed for several hours. c. postion the patient with the head of the bed elevated 30 degrees d. provide mild analgesics for pain associated with the insertion of needles

a. Medulla

The patient is admitted to the ED having difficulty with respiratory, vasomotor, and cardiac function. Which portion of the brain is affected? a. Medulla b. Cerebellum c. Parietal Lobe d. Wernicke's Area

a, c, e

What factors should be considered when taking the history of a patient with a neurologic problem? (Select all that apply) a. Avoid suggesting symptoms b. Include the CN assessment as the first assessment c. Mental status must be accurately assessed to ensure that the reported history is factual d. do a focused assessment of the neurologic system, as other body systems will not be affected e. The mode of onset and course of illness are especially important aspects of the nursing history

c. relays sensory and motor input to and from the cerebrum

What functions does the thalamus have? a. registers auditory input b. integrates past experiences c. relays sensory and motor input to and from the cerebrum d. controls and facilitates learned and automatic movements

c. The presynaptic terminal submits a nerve impulse through the synaptic cleft to the receptor site on the postsynaptic cell.

What happens at the Synapse? a. The synapse physically joins two neurons b. The nerve impulse is transmitted only from one neuron to another neuron c. The presynaptic terminal submits a nerve impulse through the synaptic cleft to the receptor site on the postsynaptic cell.

c. positive Romberg test

What is demonstrated when the patient stands with the feet close together and eyes closed and the patient sways or falls? a. pronator drift b. absent patellar reflex c. positive Romberg test d. absence of two-point discrimination

a. causes hyporeflexia and flaccidity

What is different when a lesion occurs in a lower motor neuron compared to in an upper motor neuron? a. causes hyporeflexia and flaccidity b. affects motor control of the lower body c. arises in the structures above the spinal cord d. interferes with reflex arcs in the spinal cord

b. cerebral angiography

What is the neurologic diagnostic test that has the highest risk of complications and requires frequent monitoring of neurologic and vital signs following following the procedure? a. myelogram b. cerebral angiography c. electroencephalogram d. transcranial doppler sonography

b. extension of the arm

What is the normal response to striking the tendon with a reflex hammer? a. forearm pronation b. extension of the arm c. flexion of the arm at the elbow d. flexion and supination of the elbow

d. Simultaneously stimulating both sides of the body

What method is used to assess for extinction? a. cotton wisp b. sharp and dull end of a pin c. tuning fork to bony prominences d. Simultaneously stimulating both sides of the body

b. lack of coordination

When using the heel-to-shin test, for what abnormality is the nurse assessing the patient? a. hypertonia b. lack of coordination c. extension of the toes d. loss of proprioception

c. hypoglossal (CN XII)

Which CN is tested with tongue protrusion? a. vagus (CN X) b. olfactory (CN I) c. hypoglossal (CN XII) d. glossopharyngeal (CN IX)

c. trigeminal (CN V)

Which CN responds to the corneal reflex test? a. optic (CN II) b. vagus (CN X) c. trigeminal (CN V) d. spinal accessory (CN XI)

b, d, e

Which CNs are involved with oblique eye movements? (select all that apply) a. optic b. trochlear c. trigeminal d. abducens e. oculomotor

c. Hypothalamus

Which area of the brain regulates endocrine and ANS functions? a. Basal Ganglia b. Temporal Lobe c. Hypothalamus d. Reticular activating system

b. Processing visual images

A 28-year-old female patient has been diagnosed with occipital lobe damage after a car accident. What should the nurse expect the patient to need help with? a. Being able to feel heat b. Processing visual images c. Identifying smells appropriately d. Being able to say what she means

A. nystagmus. (Nystagmus is defined as fine, rapid jerking movements of the eyes.)

A patient's eyes jerk while the patient looks to the left. You will record this finding as: A. nystagmus. B. CN VI palsy. C. oculocephalia. D. opthalmic dyskinesia.

b. protects against harmful blood-borne agents

After talking with the HCP, the patient asks what the blood-brain barrier does. what is the best description the nurse can give the patient? a. protects the brain from external trauma b. protects against harmful blood-borne agents c. provides for flexibility while protecting the spinal cord d. decreased frequency of spontaneous awakening

A. Many neurologic diseases affect one or more of these areas (Rationale: Many neurologic disorders affect the patient's mobility, strength, and coordination. These problems can alter the patient's usual activity and exercise patterns.)

Data regarding mobility, strength, coordination and activity tolerance are important for the nurse to obtain because? A. Many neurologic diseases affect one or more of these areas B. Patients are less able to identify other neurologic impairments C. These are the first functions to be affected by neurologic diseases D. Aspects of movement are the most important function of the nervous system

D. automatic movements associated with skeletal muscle activity. (A group of descending motor tracts carries impulses from the extrapyramidal system, which includes all motor systems (except the pyramidal system) concerned with voluntary movement. It includes descending pathways originating in the brainstem, basal ganglia, and cerebellum. The motor output exits the spinal cord by way of the ventral roots of the spinal nerves.)

Drugs or diseases that impair the function of the extrapyramidal system may cause loss of: A. sensations of pain and temperature B. regulation of the autonomic nervous system. C. integration of somatic and special sensory inputs. D. automatic movements associated with skeletal muscle activity.

a. Ataxia (Ataxia is a lack of coordination of movement, possibly caused by lesions of sensory or motor pathways, cerebellum disorders, or certain medications. Apraxia is the inability to perform learned movements despite having the desire and physical ability to perform them related to a cerebral cortex lesion. Anisocoria is inequality of pupil size from an optic nerve injury. Anosognosia is the inability to recognize a bodily defect or disease related to lesions in the right parietal cortex.)

When assessing a patient with a traumatic brain injury, the nurse notes uncoordinated movement of the extremities. How should the nurse document this assessment? a. Ataxia b. Apraxia c. Anisocoria d. Anosognosia

d. Pronator drift (Downward drifting of the arm or pronation of the palm is identified as pronator drift. Athetosis is a slow, writhing, involuntary movement of the extremities. Hypotonia is flaccid muscle tone, and hemiparesis is weakness of one side of the body.)

When assessing motor function of a patient admitted with a stroke, the nurse notes mild weakness of the arm. The patient also is unable to hold the arm level. How should the nurse most accurately document this finding? a. Athetosis b. Hypotonia c. Hemiparesis d. Pronator drift