Chapter 60: Assessment of Neurologic Function - ML3

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 which cranial nerve?

VIII

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

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

refrain from eating or drinking for now.

A nurse is working in a neurologist's office. The physician orders a Romberg test. What should the nurse instruct the client to do?

Close eyes and stand erect.

The nurse is assessing the pupils of a patient who has had a head injury. What does the nurse recognize as a parasympathetic effect?

Constricted pupils

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?

Occipital

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."

A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction?

"Avoid stimulants and alcohol for 24 to 48 hours before the test."

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."

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?

"The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid."

Which of the following neurotransmitters are deficient in myasthenia gravis?

Acetylcholine

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

Acoustic

A client suspected of having a distortion of cerebral arteries and veins is scheduled for a cerebral angiography. What would the nurse tell the client about the upcoming test?

Contrast will be given and a rapid sequence of radiographs will be taken.

A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first?

Assess the client for medication allergies.

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

Ataxia

Lesions in the temporal lobe may result in which type of agnosia?

Auditory

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

The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart?

CN II

What part of the brain controls and coordinates muscle movement?

Cerebellum

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.

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?

Cerebral spinal fluid leakage at the puncture site

Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed?

Clonus

A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects in the body systems, what does the nurse anticipate the liver will do?

Convert glycogen to glucose for immediate use.

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

If a client has a lower motor neuron lesion, the nurse would expect to observe which manifestation upon physical assessment?

Decreased muscle tone

Low levels of the neurotransmitter serotonin lead to which of the following disease processes?

Depression

A patient has a deficiency of the neurotransmitter serotonin. The nurse is aware that this deficiency can lead to:

Depression.

Which is a sympathetic effect of the nervous system?

Dilated pupils

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 the vagus nerve

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?

Encourage the client to drink liberal amounts of fluids

Which cerebral lobes is the largest and controls abstract thought?

Frontal

Which lobe of the brain is responsible for concentration and abstract thought?

Frontal

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

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?

Helicopod

Which of the following areas of the brain are responsible for temperature regulation? You Selected:

Hypothalamus

What is the function of cerebrospinal fluid (CSF)?

It cushions the brain and spinal cord.

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?

Lateral recumbent, with thighs flexed

A 53-year-old man presents to the emergency department with a chief complaint of inability to form words, and numbness and weakness of the right arm and leg. Where would you locate the site of injury?

Left frontoparietal region

A client presents to the emergency department status postseizure. The health care provider wants to measure CSF pressure. What test might be ordered on this client?

Lumbar puncture

A patient has difficulty interpreting his awareness of body position in space. Which lobe is most likely to be damaged?

Parietal

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?

Position the client flat as directed.

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 that is slowing transmission of the motor neurons, in what would the nurse anticipate a delayed reaction?

Response due to interrupted impulses from the central nervous system

In reviewing a client's history and physical examination, a nurse finds that the client was found positive for ataxia during the physician's neurological testing. Which nursing diagnosis will be a priority for this client?

Risk for falls

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

Serotonin

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?

Tactile agnosia

Which cerebral lobe contains the auditory receptive areas?

Temporal

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

Twelve

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 Pinpoint pupils Absence of pupillary response

A nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm?

cerebral angiography

If a client has a lower motor neuron lesion, the nurse would expect the client to exhibit

decreased muscle tone.

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:

evaluation of the corneal reflex response.

Lower motor neuron lesions cause

flaccid muscles.

To assess a client's cranial nerve function, a nurse should assess:

gag reflex.

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.

The nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response?

observing the client's response to painful stimulus

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

occipital

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:

sympathetic nervous system.

A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in

thought content.

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?

v

The nurse is performing a neurologic assessment on a client diagnosed with a stroke and cannot elicit a gag reflex. This deficit is related to which of the following cranial nerves?

x