CHAPTER 60: ASSESSMENT OF NEUROLOGIC FUNCTION

A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize what action? A. Withholding stimulants 24 to 48 hours prior to exam B. Removing all metal-containing objects C. Instructing the client to void prior to the MRI D. Initiating an IV line for administration of contrast

ANS: B Rationale: Client preparation for an MRI consists of removing all metal-containing objects prior to the examination. Withholding stimulants would not affect an MRI; this relates to an electroencephalography (EEG). Instructing the client to void is client preparation for a lumbar puncture. Initiating an IV line for administration of contrast would be done if the client was having a CT scan with contrast.

The nurse is planning the care of a client with Parkinson disease. The nurse should be aware that treatment will focus on what pathophysiologic phenomenon? A. Premature degradation of acetylcholine B. Decreased availability of dopamine C. Insufficient synthesis of epinephrine D. Delayed reuptake of serotonin

ANS: B Rationale: Parkinson disease develops from decreased availability of dopamine, not acetylcholine, epinephrine, or serotonin.

A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-related changes that may influence the assessment results. Of what phenomenon should the nurse be aware? A. Hyperactive deep tendon reflexes B. Reduction in cerebral blood flow C. Increased cerebral metabolism D. Hypersensitivity to painful stimuli

ANS: B Rationale: Reduction in cerebral blood flow (CBF) is a change that occurs in the normal aging process. Deep tendon reflexes can be decreased or, in some cases, absent. Cerebral metabolism decreases as the client advances in age. Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used.

The health care provider has prescribed a somatosensory evoked responses (SERs) test for a client for whom the nurse is caring. The nurse is justified in suspecting that this client may have a history of what type of neurologic disorder? A. Hypothalamic disorder B. Demyelinating disease C. Brainstem deficit D. Diabetic neuropathy

ANS: B Rationale: SERs are used to detect deficits in the spinal cord or peripheral nerve conduction and to monitor spinal cord function during surgical procedures. The test is also useful in the diagnosis of demyelinating diseases, such as multiple sclerosis and polyneuropathies, where nerve conduction is slowed. The test is not done to diagnose hypothalamic disorders, brainstem deficits, or diabetic neuropathies.

A client is scheduled for a myelogram, and the nurse explains to the client that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests? A. Lumbar puncture B. MRI C. Cerebral angiography D. EEG

ANS: A Rationale: A myelogram is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. Client preparation for a myelogram would be similar to that for lumbar puncture. The other listed diagnostic tests do not involve lumbar puncture.

What neurologic assessment should the nurse perform to gauge the client's function of cranial nerve I? A. Have the client identify familiar odors with the eyes closed. B. Assess papillary reflex. C. Utilize the Snellen chart. D. Test for air and bone conduction (Rinne test).

ANS: A Rationale: Cranial nerve I is the olfactory nerve. The client's sense of smell could be assessed by asking him or her to identify common odors. Assessment of papillary reflex does not address the olfactory function of cranial nerve I. The Snellen chart would be used to assess cranial nerve II (optic).

A client is being given a medication that stimulates the parasympathetic system. Following administration of this medication, the nurse should anticipate what effect? A. Constricted pupils B. Dilated bronchioles C. Decreased peristaltic movement D. Relaxed muscular walls of the urinary bladder

ANS: A Rationale: Parasympathetic stimulation results in constricted pupils, constricted bronchioles, increased peristaltic movement, and contracted muscular walls of the urinary bladder.

A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution? A. Hot or cold packs B. Analgesics C. Anti-inflammatory medications D. Whirlpool baths

ANS: A Rationale: Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used. The older client may be burned or suffer frostbite before being aware of any discomfort. Any medication is used with caution in older adults, but not because of the decreased sense of heat or cold. Whirlpool baths are generally not a routine treatment prescribed for older adults.

When assessing a 36-year-old male, the nurse gently strokes the client's right palm using a cotton applicator. As the nurse strokes the client's palm the nurse then checks to see if the client will begin to grasp the applicator. This assessment is associated with which of the following reflexes? A. Pathologic B. Superficial C. Deep tendon D. Brachioradialis

ANS: A Rationale: Reflexes are classified either as pathological, superficial, or deep tendon. Pathological reflexes often represent the emergence of earlier reflexes that disappeared with the maturity of the nervous system. The palmar reflex is associated with assessing for a pathologic reflex. Superficial and deep tendon reflexes are not assessed using this type of test. Brachioradialis is a type of deep tendon reflex. Reflex tests are performed as a part of neurological assessment to quickly determine an intact spinal cord.

A client is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this client, the nurse has the client stick out the tongue and move it back and forth. What is the nurse assessing? A. Function of the hypoglossal nerve B. Function of the vagus nerve C. Function of the spinal nerve D. Function of the trochlear nerve

ANS: A Rationale: The hypoglossal nerve is the 12th cranial nerve. It is responsible for movement of the tongue. None of the other listed nerves affects motor function in the tongue.

A health care provider has prescribed a standard electroencephalogram (EEG) test for the client. What general instructions should the nurse provide to the client? Select all that apply A. The procedure generally takes 45 to 60 minutes. B. Please remove all jewelry and any metal objects prior to the procedure C. This procedure uses a water-soluble lubricant for electrode contact which can be easily wiped off and removed using shampoo D. If you feel nervous about the test I can provide you a light sedative medication to ease your anxiety E. Please refrain from drinking coffee and any caffeinated beverages the morning prior to the procedure F. It is required that you withhold taking your anticonvulsant medication 72 hours before the procedure.

ANS: A, C, E Rationale: A standard EEG usually takes 45 to 60 minutes. Typically, a water-soluble lubricant is used to aid electrode contact. This lubricant is easily removed with shampoo. Coffee, tea, chocolate, and cola drinks are omitted from the meal before the test because of their stimulating effect. Sedation is not considered because it may lower the seizure threshold in clients and it may alter brain activity. Stimulants, tranquilizers, anticonvulsants, and depressants are advised to be held 24 to 48 hours, not 72 hours, prior to the procedure because these medications can alter the EEG wave patterns or mask the abnormal wave patterns of seizure disorders. The client is instructed to eat before the test because keeping the client NPO (nothing by mouth) can alter blood glucose levels and cause changes in brain wave patterns. The client can wear jewelry during the test, although some facilities will request that earrings be removed.

The nurse is doing an initial assessment on a client newly admitted to the unit with a diagnosis of cerebrovascular disease. The client has difficulty copying a figure that the nurse has drawn and is diagnosed with visual receptive aphasia. What brain region is primarily involved in this client's deficit? A. Temporal lobe B. Parietal-occipital area C. Inferior-posterior frontal areas D. Posterior frontal area

ANS: B Rationale: Difficulty copying a figure that the nurse has drawn would be considered visual receptive aphasia, which involves the parietal-occipital area. Expressive aphasia, the inability to express oneself, is often associated with damage to the frontal area. Receptive aphasia, the inability to understand what someone else is saying, is often associated with damage to the temporal lobe area.

The nurse is performing a neurologic assessment of a client whose injuries have rendered the client unable to follow verbal commands. How should the nurse proceed with assessing the client's level of consciousness (LOC)? A. Assess the client's vital signs and correlate these with the client's baselines. B. Assess the client's eye opening and response to stimuli. C. Document that the client currently lacks a level of consciousness. D. Facilitate diagnostic testing in an effort to obtain objective data.

ANS: B Rationale: If the client is not alert or able to follow commands, the examiner observes for eye opening; verbal response and motor response to stimuli, if any; and the type of stimuli needed to obtain a response. Vital signs and diagnostic testing are appropriate, but neither will allow the nurse to gauge the client's LOC. Inability to follow commands does not necessarily denote an absolute lack of consciousness.

In the course of a focused neurologic assessment, the nurse is palpating the client's major muscle groups at rest and during passive movement. Data gleaned from this assessment will allow the nurse to describe which of the following aspects of neurologic function? A. Muscle dexterity B. Muscle tone C. Motor symmetry D. Deep tendon reflexes

ANS: B Rationale: Muscle tone (the tension present in a muscle at rest) is evaluated by palpating various muscle groups at rest and during passive movement. Data from this assessment do not allow the nurse to ascertain the client's dexterity, reflexes, or motor symmetry.

A trauma client in the ICU has been declared brain dead. What diagnostic test is used in making the best determination that the brain's electrical activity has ceased? A. Magnetic resonance imaging (MRI) B. Electroencephalography (EEG) C. Electromyography (EMG) D. Computed tomography (CT)

ANS: B Rationale: The EEG can be used to determine that brain activity has ceased.. MRI and CT scans have been used to declare brain death by showing an absence of blood flow, but this is not the best way to determine that brain activity has ceased. EMG is not normally used to determine brain death.

A nurse is performing a complex neurological assessment on a client recently diagnosed with Alzheimer disease. What question should the nurse anticipate to ask when assessing the client's language ability? A. "How are a pencil and pen alike?" B. "Can you write your name on this blank sheet of paper?" C. "Can you tell me what year it is?" D. "What is the name of the president of the United States?"

ANS: B Rationale: When assessing written and spoken language ability, clients are usually asked to read a newspaper article and explain the meaning. Clients are also asked to write their name or copy a simple figure drawn by the examiner. Comparison questions are associated with assessing a client's intellectual function. Asking about the year and current name of the president are associated with assessing a client's mental status.

The nurse is preparing to assess a client with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply. A. The ability to select basic medications for the neurologic dysfunction B. Understanding of the tests used to diagnose neurologic disorders C. Knowledge of nursing interventions related to assessment and diagnostic testing D. Knowledge of the anatomy of the nervous system E. The ability to interpret the results of diagnostic tests

ANS: B, C, D Rationale: Assessment requires knowledge of the anatomy and physiology of the nervous system and an understanding of the array of tests and procedures used to diagnose neurologic disorders. Knowledge about the nursing implications and interventions related to assessment and diagnostic testing is also essential. Selecting medications and interpreting diagnostic tests are beyond the normal scope of the nurse.

In which specific instances should the nurse assess the client's cranial nerves? Select all that apply. A. When a neurogenic bladder develops B. When level of consciousness is decreased C. With brain stem pathology D. In the presence of peripheral nervous system disease E. When a spinal reflex is interrupted

ANS: B, C, D Rationale: Cranial nerves are assessed when level of consciousness is decreased, with brain stem pathology, or in the presence of peripheral nervous system disease. Abnormalities in muscle tone and involuntary movements are less likely to prompt the assessment of cranial nerves, since these nerves do not directly mediate most aspects of muscle tone and movement.

When caring for a client with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would most likely elicit a response from cranial nerve VII? A. Palpate trapezius muscle while client shrugs shoulders against resistance. B. Administer the whisper or watch tick test. C. Observe for facial movement symmetry, such as a smile. D. Note any hoarseness in the client's voice.

ANS: C Rationale: Cranial nerve VII is the facial nerve. An appropriate assessment technique for this cranial nerve would include observing for symmetry while the client performs facial movements: smiles, whistles, elevates eyebrows, and frowns. Cranial nerve XI (spinal accessory) does not affect the muscles of the face. Assessing cranial nerve VIII (acoustic) would involve evaluating hearing. Cranial nerve X (vagus) does not affect the face.

A client has been recently diagnosed with myasthenia gravis. Which is indicative of a person diagnosed with myasthenia gravis? A. Excessive serotonin activity in the brain B. Decreased dopamine activity in the brain C. Impairment of acetylcholine binding to muscle cells D. Defects in the expression of acetylcholine receptors

ANS: C Rationale: In myasthenia gravis, acetylcholine binding to muscle cells is impaired. A breakdown essentially occurs in the communication between nerves and muscles. This results in weakness of extremities and difficulties with speech and chewing. Many neurologic disorders are due, at least in part, to an imbalance in neurotransmitters. Decreased dopamine activity in the brain is suggestive of Parkinson. Excessive or too much serotonin activity in the brain can cause a variety of mild to severe symptoms. Some of these include high blood pressure, shivering, confusion and/or high fever. Defects in the expression of acetylcholine receptors is more indicative of amyotrophic lateral sclerosis (ALS). ALS affects motor neurons directly.

A client is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the client in preparation for this test? A. "No metal objects can enter the procedure room." B. "You need to fast for 8 hours prior to the test." C. "You will need to lie still throughout the procedure." D. "There will be a lot of noise during the test."

ANS: C Rationale: Preparation for CT scanning includes teaching the client about the need to lie quietly throughout the procedure. If the client were having an MRI, metal and noise would be appropriate teaching topics. There is no need to fast prior to a CT scan of the brain.

The nurse is providing information to a client about neurological disorders associated with genetic defects. The nurse knows which disease is considered an autosomal dominant disorder? A. Duchenne muscular dystrophy B. Parkinson disease C. Huntington disease D. Fragile X syndrome

ANS: C Rationale: Several neurologic disorders are associated with genetic abnormalities. These diseases can have distinct inheritance patterns including: autosomal dominant, Autosomal recessive, or X-linked. Autosomal dominant diseases include: familial Alzheimer disease, myotonic dystrophies, Von Hippel-Lindau syndrome, Huntington disease, neurofibromatosis, and cerebral arteriopathy. Duchenne muscular dystrophy and fragile X syndrome are X-linked disorders. Parkinson disease does not have a distinct inheritance pattern.

During the performance of the Romberg test, the nurse observes that the client sways slightly. What is the nurse's most appropriate action? A. Facilitate a referral to a neurologist. B. Reposition the client supine to ensure safety. C. Document successful completion of the assessment. D. Follow up by having the client perform the Rinne test.

ANS: C Rationale: Slight swaying during the Romberg test is normal, but a loss of balance is abnormal and is considered a positive Romberg test. Slight swaying is not a significant threat to the client's safety. The Rinne test assesses hearing, not balance.

A client is having a "fight or flight response" after receiving a bad disease prognosis. What affect will this have on the client's sympathetic nervous system? A. Constriction of blood vessels in the heart muscle B. Constriction of bronchioles C. Increase in the secretion of sweat D. Constriction of pupils

ANS: C Rationale: Sympathetic nervous system stimulation results in dilated blood vessels in the heart and skeletal muscle, dilated bronchioles, increased secretion of sweat, and dilated pupils.

A trauma client was admitted to the intensive care unit (ICU) with a brain injury that resulted in a change in level of consciousness and altered vital signs. The client subsequently became diaphoretic and agitated. The nurse should recognize which of the following syndromes as the most plausible cause of these symptoms? A. Adrenal crisis B. Hypothalamic collapse C. Sympathetic storm D. Cranial nerve deficit

ANS: C Rationale: Sympathetic storm is a syndrome associated with changes in level of consciousness, altered vital signs, diaphoresis, and agitation that may result from hypothalamic stimulation of the sympathetic nervous system following traumatic brain injury. Alterations in cranial nerve or adrenal function would not have this result.

The nurse caring for an 80-year-old client knows that the client has a preexisting history of dulled tactile sensation. The nurse should first consider what possible cause for this client's diminished tactile sensation? A. Damage to cranial nerve VIII B. Adverse medication effects C. Age-related neurologic changes D. An undiagnosed cerebrovascular disease in early adulthood

ANS: C Rationale: Tactile sensation is dulled in the older adult client due to a decrease in the number of sensory receptors. While thorough assessment is necessary, it is possible that this change is unrelated to pathophysiologic processes.

A nurse is performing a neurological assessment on a client at home. During the assessment, the nurse notices that the client has a flat affect. Which lobe of the brain is responsible for a person's affect? A. Parietal lobe B. Temporal lobe C. Frontal lobe D. Occipital lobe

ANS: C Rationale: The frontal lobe is the largest lobe located in front of the brain. It is responsible in large part for a person's affect, judgment, personality, and inhibitions. The parietal lobe is essential to a person's awareness of body position in space, size and shape discrimination, and right-left orientation. The temporal lobe plays a role in memory of sound and understanding of language and music. The occipital lobe is responsible for visual interpretation and memory.

A client in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows the brain regulates body temperature in which of the following areas? A. Cerebellum B. Thalamus C. Hypothalamus D. Midbrain

ANS: C Rationale: The hypothalamus plays an important role in the endocrine system because it regulates the pituitary secretion of hormones that influence metabolism, reproduction, stress response, and urine production. It works with the pituitary to maintain fluid balance through hormonal release and maintains temperature regulation by promoting vasoconstriction or vasodilatation. The cerebellum, thalamus, and midbrain are not directly involved in temperature regulation.

The nurse is caring for a client with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the client's neurologic assessment? A. Decreased muscle tone B. Flaccid paralysis C. Loss of voluntary control of movement D. Slow reflexes

ANS: C Rationale: Upper motor neuron lesions do not cause muscle atrophy, flaccid paralysis, or slow reflexes. However, upper motor neuron lesions normally cause loss of voluntary control.

A nurse is assessing reflexes in a client with hyperactive reflexes. When the client's foot is abruptly dorsiflexed, it continues to "beat" two to three times before settling into a resting position. How should the nurse document this finding? A. Rigidity B. Flaccidity C. Clonus D. Ataxia

ANS: C Rationale: When reflexes are very hyperactive, a phenomenon called clonus may be elicited. If the foot is abruptly dorsiflexed, it may continue to "beat" two to three times before it settles into a position of rest. Rigidity is an increase in muscle tone at rest characterized by increased resistance to passive stretch. Flaccidity is lack of muscle tone. Ataxia is the inability to coordinate muscle movements, resulting in difficulty walking, talking, and performing self-care activities.

A client had a lumbar puncture performed at the outpatient clinic and the nurse phoned the client and family that evening. What does this phone call enable the nurse to determine? Select all that apply. A. What the client's and family's expectations of the test are. B. Whether the client's family had any questions about why the test was necessary. C. Whether the client has had any complications from the test. D. Whether the client understood accurately why the test was done. E. The necessary steps for the client and family to take should complications arise.

ANS: C, E Rationale: Contacting the client and family after diagnostic testing enables the nurse to determine whether they have any questions about the procedure, whether the client had any untoward results, and what to do should complications arise. Since the test was done as an outpatient; monitoring and care are being provided by the family. The health of the client becomes a team effort so any communication by the nurse should include both parties. The other listed information should have been elicited from the client and family prior to the test.

A 72-year-old man has been brought to his primary care provider by the client's daughter, who claims that the client has been experiencing uncharacteristic lapses in memory. What principle should underlie the nurse's assessment and management of this client? A. Loss of short-term memory is normal in older adults, but loss of long-term memory is pathologic. B. Lapses in memory in older adults are considered benign unless they have negative consequences. C. Gradual increases in confusion accompany the aging process. D. Thorough assessment is necessary because changes in cognition are always considered to be pathologic.

ANS: D Rationale: Although mental processing time decreases with age, memory, language, and judgment capacities remain intact. Change in mental status should never be assumed to be a normal part of aging.

A 26-year-old female client, who is breastfeeding a newborn, is due to undergo a computed tomography (CT) scan with dye contrast. What instruction should the nurse provide to the client based on this procedure? A. "Do not breastfeed your baby for two weeks after the procedure as recommended by your provider." B. "Limit your intake of water and alcohol following the procedure." C. "Do not eat or cook any shellfish prior to the procedure." D. "Stop breastfeeding for the time frame given by the provider within the nuclear medicine department."

ANS: D Rationale: Breastfeeding women are instructed by the nuclear medicine department to stop for a certain time period when undergoing nuclear medicine/CT scan treatment. Clients are assessed to see if an allergy to shellfish/iodine exists prior to the procedure. Clients are encouraged to drink plenty of fluids after the procedure to help the kidneys clear the dye out of the body.

The neurologic nurse is testing the function of a client's cerebellum and basal ganglia. What action will most accurately test these structures? A. Have the client identify the location of a cotton swab on his or her skin with the eyes closed. B. Elicit the client's response to a hypothetical problem. C. Ask the client to close his or her eyes and discern between hot and cold stimuli. D. Guide the client through the performance of rapid, alternating movements.

ANS: D Rationale: Cerebellar and basal ganglia influence on the motor system is reflected in balance control and coordination. Coordination in the hands and upper extremities is tested by having the client perform rapid, alternating movements and point-to-point testing. The cerebellum and basal ganglia do not mediate cutaneous sensation or judgment.

A client for whom the nurse is caring has positron emission tomography (PET) scheduled. In preparation, what should the nurse explain to the client? A. "The test will temporarily limit blood flow through the brain." B. "An allergy to iodine precludes getting the radio-opaque dye." C. "The client will need to endure loud noises during the test." D. "The test may result in dizziness or lightheadedness."

ANS: D Rationale: Key nursing interventions for PET scan include explaining the test and teaching the client about inhalation techniques and the sensations (e.g., dizziness, lightheadedness, and headache) that may occur. A PET scan does not impede blood flow through the brain. An allergy to iodine precludes the dye for an MRI, and loud noise is heard in an MRI.

The nurse is admitting a client to the unit who is diagnosed with a lower motor neuron lesion. What entry in the client's electronic record is most consistent with this diagnosis? A. "Client exhibits increased muscle tone." B. "Client demonstrates normal muscle structure with no evidence of atrophy." C. "Client demonstrates hyperactive deep tendon reflexes." D. "Client demonstrates an absence of deep tendon reflexes."

ANS: D Rationale: Lower motor neuron lesions cause flaccid muscle paralysis, muscle atrophy, decreased muscle tone, and loss of voluntary control.

The nurse is conducting a focused neurologic assessment and is assessing the client's gag reflex. How should the nurse best perform this aspect of the assessment? A. Depress the client's tongue with a sterile tongue depressor. B. Ask the client to swallow a small quantity of any soft food. C. Observe the client swallowing a small mouthful of water. D. Lightly touch the client's pharynx with a cotton swab.

ANS: D Rationale: The gag reflex is elicited by gently touching the back of the pharynx with a cotton-tipped applicator, first on one side of the uvula and then the other. The gag reflex is not assessed by having the client swallow or by depressing the tongue.

A client is currently being stimulated by the parasympathetic nervous system. What effect will this nervous stimulation have on the client's bladder? A. Urinary retention B. Bladder spasms C. Urge incontinence D. Bladder contract

ANS: D Rationale: The parasympathetic division of the nervous system causes contraction (stimulation) of the urinary bladder muscles whereas the sympathetic division produces relaxation (inhibition) of the urinary bladder.

An older adult client is being discharged home. The client lives alone and has atrophy of the olfactory organs. The nurse tells the client's family that it is essential that the client have what installed in the home? A. Grab bars B. Nonslip mats C. Baseboard heaters D. A smoke detector

ANS: D Rationale: The sense of smell deteriorates with age. The olfactory organs are responsible for smell. This may present a safety hazard for the client because he or she may not smell smoke or gas leaks. Smoke detectors are universally necessary, but especially for this client.

What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brain's surface? A. Dura mater B. Arachnoid C. Fascia D. Pia mater

ANS: D Rationale: The term "meninges" describes the fibrous connective tissue that covers the brain and spinal cord. The meninges have three layers: the dura mater, arachnoid, and pia mater. The pia mater is the innermost membrane that hugs the brain closely and extends into every fold of the brain's surface. The dura mater, the outermost layer, covers the brain and spinal cord. The arachnoid, the middle membrane, is responsible for the production of cerebrospinal fluid. This is not known as "fascia."