Chapter 65 med surg (Assessment of function worksheet)
The nurse is performing an assessment of cranial nerve function and ask the the pt to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The pt is unable to smell any of the odors. The nurse is aware the pt has a dsyfunction of what cranial nerve?
CN I
A pt comes to the ED 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
II Optic
Eye movement
V Trigeminal
Facial sensation
A pt had a lumbar puncture 3 days ago in the out pt clinic and calls the nurse with complaints of a throbbing headache. What can the nurse educate the pt to do to relief of the discomfort? Select all apply
Force fluid (unless contraindicated) Get plenty of rest Take some over the counter anaglesics
A pt who has suffered a stroke is unable to maintain respirations and so is intubated and placed on a mechanical ventilation support. What portion of the brain is mostly likely responsible for the inability to breathe?
Brain stem
The pre ganglions fibers of the sympathetic neurons are located in the segment of the spina cord identified as ____ to _____
C8 L3
The nurse obtains a senile eye chart when assessing the cranial nerve function. What cranial nerve is the nurse testing when the nurse uses this chart?
CN II
The brain center responsible for balancing and coordination is the _______
Cerebelum
A pt is scheduled for a EEG in the morning. What food on the patient tray should the nurse remove prior to test?
Coffee
The nurse is accessing the pupils of a pt who has had a head injury. What does the nurse recognize as a parasympathetic effect?
Constricted pupils
Parkinson's disease is caused by an imbalance in the neurotransmitter known as
Dopamine
A pt is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elected. What dysfunction does the nurse determine the pt has?
Dysfunction of the vagus nerve
Norepinephrine
Excitatory response, mostly affecting moods
Enkephalin
Excitatory; inhibits pain transmisssion
III Oculomotor
Eye Movement
IV Trochlear
Eye Movement
VI Abducer
Eye Movement
The major receiving and communication center for the afferent sensory nerve is the ____
Thalamus
XII Hypoglosseal
Tongue movement
XI Spinal accessory
Trapieze, sternomastoid muscle
I Olfactory
Vision
The nurse is caring for a pt who was involved in a motor vehicle accident and sustained a head injury. When accessing DTR, the nurse observes diminished reflexes. How would she document this finding?
1+
The normal adult produces about _____ml of cerebral spinal fluid daily from the ventricles
150
The nurse is assisting with a lumbar puncture and observes that when the physician obtain CSF,it is clear and colorless. What does this finding indicate?
A normal finding; the fluid will be sent for testing to determine other factors
The parasympathetic division of the autonomic nervous system yields impulses that are medicated by the secretions of ______ the dominant neurotransmitter in the parasympathetic nervous system function
ACETOCOLINE
Dopamine
Affects behavior attention, and fine movement
A persons personality and judgement are controlled by the area of the brain known as the ______ lobe
Frontal
Voluntary muscle control is governed by a vertical band of motor cortex located in the _______ lobe
Frontal
A pt sustained a head injury during a fall and has changed in personality and affect, What part of the brain does the nurse recognize has been affected in this injury?
Frontal lobe
A pt is having a lumbar puncture and the physician has removed 20 ml of CSF. What using intervention is an priority after the procedure?
Have the pt lie flat for 6 hours
VIII Vestibulato
Hearing & equilibriumu
The sleep wake cycle regulator and sites the hunger center is known as _____
Hypothalamus
A pt arrives to have na MRI done in the outpatient department. What info provided by the pt warrants further assessment to prevent complications related to MRI?
I am trying to quit smoking and have a patch on
A pt has expressive speaking aphasia after having a stroke. which portion of the brain does the nurse know has been affected?
Inferior posterior frontal areas
Serotonin
Inhibits pain pathway and control sleep
gamma-aminobutyric acid
Muscle and nerve inhibitory transmisssion
The master gland is also known as the _____gland
Pituitary
Acetylcholine
Primary excitatory; can produce vagal stimulation of heart
The nurse is performing a neurological assessment and request that the pt stand with eyes open and then closed for 20 seconds to assess balance. What type of test is the nurse performing?
Romberg test
______ is a neurotransmitter that helps control mood and sleep.
Serotonin
X Vagus
Swallowing, gastric motoility
IX Glossopharyngeal
Taste
VII Facial
Taste & Expression
The lobe of the cerebral cortex that is responsible for the understanding of language and music is the ____ lobe.
Temporal
