Chapter 65: 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? "Lying on your left side will be fine during the procedure." "There's no other option but to assume the knee-chest position." "Although the required position may not be comfortable, it will make the procedure safer and easier to perform." "I'll report your concerns to the physician."

"Although the required position may not be comfortable, it will make the procedure safer and easier to perform." Rationale: The nurse should explain that the knee-chest position is necessary to make the procedure safer and easier to perform. Lying on his left side won't make the procedure easy or safe to perform. The nurse shouldn't simply tell the client there is no other option because the client is entitled to understand the rationale for the required position. Reporting the client's concerns to the physician won't meet the client's needs in this situation.

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

"Do you have any problems with balance?" Rationale: To evaluate cerebellar function, the nurse should ask the client about problems with balance and coordination. The nurse asks about difficulty speaking or swallowing to assess the functions of cranial nerves IX, X, and XII. Questions about muscle strength help her evaluate the client's motor system.

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? "It can mean a traumatic puncture or a subarachnoid bleed." "It can mean a bleed around the hypothalamus or damage from the needle." "It can mean the spinal cord was damaged or a traumatic puncture." "It can mean a subarachnoid bleed or damage to the spinal cord."

"It can mean a traumatic puncture or a subarachnoid bleed." Rationale: 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.

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." Rationale: The Romberg test screens for balance. The client stands with feet together and arms at the side, first with eyes open and then with both eyes closed for 20 to 30 seconds. Slight swaying is normal, but a loss of balance is abnormal and is considered a positive Romberg test.

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: Midbrain. Cerebellum. Pons. Medulla oblongata.

Cerebellum. Rationale: 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.

There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected with decreased visual fields. Cranial nerve I Cranial nerve II Cranial nerve III Cranial nerve IV

Cranial nerve II Rationale: The three sensory cranial nerves are I, II and VIII. Cranial nerve II (optic) is affected with decreased visual fields and acuity.

Which lobe of the brain is responsible for concentration and abstract thought? Frontal Parietal Temporal Occipital

Frontal Rationale: The major functions of the frontal lobe are concentration, abstract thought, information storage or memory, and motor function. The parietal lobe analyzes sensory information such as pressure, vibration, pain, and temperature. The occipital lobe is the primary visual cortex. The temporal lobe contains the auditory receptive areas located around the temples.

A male client is scheduled for an electroencephalogram (EEG). When the nurse caring for the client is preparing him for the test, the client states that during childhood he was mildly electrocuted but miraculously lived. Therefore, he is quite afraid of going through an EEG. In what ways can the nurse help dispel the client's fear regarding the test? Distract the client's attention from the test. Inform the client that he will not experience any electrical shock. Inform the client that he will experience only mild electrical shock. Encourage adequate water intake by the client.

Inform the client that he will experience only mild electrical shock. Rationale: An EEG records the electrical impulses generated by the brain. To prepare the client for the test, the nurse informs the client that he or she will not experience any electrical shock. The source of electrical energy is the client's neural activity within the brain and not any external electrical energy. Ensuring adequate water intake or distracting the attention of the client will not comfort the client about the technical nature of the test.

A critical care nurse is documenting her assessment of a client she is caring for. The client is status post-resection of a brain tumor. The nurse documents that the client is flaccid on the left. What does this mean? The client has an abnormal posture response to stimuli. The client is not responding to stimuli. The client is hyperresponsive on the left. The client is hyporesponsive on the left.

The client is not responding to stimuli. Rationale: Flaccidity is when the client makes no motor response to stimuli. Flaccidity is a motor assessment.

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 Rationale: Anticonvulsant agents, tranquilizers, stimulants, and depressants should be withheld 24 to 48 hours before an EEG because these medications can alter EEG wave patterns or mask the abnormal wave patterns of seizure disorders. To increase the chances of recording seizure activity, it is sometimes recommended that the client be deprived of sleep on the night before the EEG. Coffee, tea, chocolate, and cola drinks are omitted in the meal before the test because of their stimulating effect. However, meals are not omitted, because an altered blood glucose concentration can cause changes in brain wave patterns. The client is informed that a standard EEG takes 45 to 60 minutes; a sleep EEG requires 12 hours.

A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with: body temperature control. balance and equilibrium. visual acuity. thinking and reasoning.

body temperature control. Rationale: The body's thermostat is located in the hypothalamus; therefore, injury to that area can cause problems with body temperature control. Balance and equilibrium problems are related to cerebellar damage. Visual acuity problems would occur following occipital or optic nerve injury. Thinking and reasoning problems are the result of injury to the cerebrum.

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: cease function and shunt blood to the heart and lungs. convert glycogen to glucose for immediate use. produce a toxic byproduct in relation to stress. maintain a basal rate of functioning.

convert glycogen to glucose for immediate use. Rationale: When the body is under stress, the sympathetic nervous system is activated readying the body for action. The effect of the body is to mobilize stored glycogen to glucose to provide additional energy for body action.

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

little to no muscle atrophy. Rationale: Upper motor neuron lesions cause little to no muscle atrophy but do cause loss of voluntary control. Lower motor neuron lesions cause decreased muscle tone, flaccidity, and absent or decreased reflexes.

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: identification of information due to slowed passages of information to brain. cognitive ability to understand relayed information. processing information transferred from the environment. response due to interrupted impulses from the central nervous system

response due to interrupted impulses from the central nervous system Rationale: 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.