Chapter 65 Med/Surg
To help assess a client's cerebral function, a nurse should ask: a) "Have you noticed a change in your muscle strength?" b) "Have you had any problems with your eyes?" c) "Have you had any problems with coordination?" d) "Have you noticed a change in your memory?"
"Have you noticed a change in your memory?" To assess cerebral function, the nurse should ask about the client's level of consciousness, orientation, memory, and other aspects of mental status. Questions about muscle strength help evaluate the client's motor system. Questions about coordination help her assess cerebellar function. Questions about eyesight help the nurse evaluate the cranial nerves associated with vision.
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? a) "I have been trying to get an appointment for so long." b) "I am trying to quit smoking and have a patch on." c) "My legs go numb sometimes when I sit too long." d) "I have not had anything to eat or drink since 3 hours ago."
"I am trying to quit smoking and have a patch on." Before the patient enters the room where the MRI is to be performed, all metal objects and credit cards (the magnetic field can erase them) must be removed. This includes medication patches that have a metal backing and metallic lead wires; these can cause burns if not removed (Bremner, 2005).
The nurse is caring for a patient who was involved in a motor vehicle accident and sustained a head injury. When assessing deep tendon reflexes (DTR), the nurse observes diminished or hypoactive reflexes. How will the nurse document this finding? 3+ 1+ 2+ 0
1+ Diminished or hypoactive DTRs are indicated by a score of 1+, no response by a score of 0, a normal response by a score of 2+, and an increased response by a score of 3+.
The physician's office 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? a)Myelogram b) Cerebral angiography c) Echoencephalography d) Electroencephalogram
Cerebral angiography The nurse would anticipate a cerebral angiography, which detects distortion of the cerebral arteries and veins . A milligram detects abnormalities of the spinal canal. An electroencephalogram records electrical impulses of the brain. An echoencephalography is an ultrasound of the structures of the brain
Which term refers to a method of recording, in graphic form, the electrical activity of a muscle? a) Electrocardiography b) Electrogastrography c) Electroencephalography d) Electromyography
Electromyography An electromyogram is obtained by inserting needle electrodes into the skeletal muscles to measure changes in the electrical potential of the muscles. Electroencephalography is a method of recording, in graphic form, the electrical activity of the brain. Electrocardiography is performed to assess the electrical activity of the heart. Electrogastrography is an electrophysiologic study performed to assess gastric motility disturbances.
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: a) processing information transferred from the environment. b) identification of information due to slowed passages of information to brain. c) cognitive ability to understand relayed information. d) response due to interrupted impulses from the central nervous system
response due to interrupted impulses from the central nervous system 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.
A nurse is evaluating a client's cranial nerves during a routine examination. To assess the function of cranial nerve XII (hypoglossal), the nurse should assess the client's ability to: a) elevate the shoulders, both with and without resistance. b) read an eye chart from a distance of 20?. c) stick out the tongue and move it rapidly from side to side and in and out. d) smell and identify a nonirritating, aromatic odor.
stick out the tongue and move it rapidly from side to side and in and out. To test cranial nerve XII, which controls tongue movement, the nurse should instruct the client to stick out the tongue and move it rapidly from side to side and in and out. The nurse would ask the client to smell and identify a nonirritating, aromatic odor when testing the function of cranial nerve I, the olfactory cranial nerve. Asking the client to read an eye chart is part of assessing cranial nerve II, the optic cranial nerve. Having the client elevate the shoulders with and without resistance is part of assessing cranial nerve XI, the spinal accessory cranial nerve that innervates the sternocleidomastoid muscle and the upper portion of the trapezius muscle.
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? a) "Lying on your left side will be fine during the procedure." b) "There's no other option but to assume the knee-chest position." c) "Although the required position may not be comfortable, it will make the procedure safer and easier to perform." d) "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." 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.
Which of the following neurotransmitters are deficient in myasthenia gravis? GABA Dopamine Serotonin Acetylcholine
Acetylcholine A decrease in the amount of acetylcholine causes myasthenia gravis. A decrease of serotonin leads to depression. Parkinson's disease is caused by a depletion of dopamine. Decreased levels of GABA may cause seizures.
A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first? a) Obtain two large-bore IV lines. b) Obtain a blood sample to evaluate BUN and creatinine concentrations. c) Maintain the client NPO for 6 hours before the test. d) Assess the client for medication allergies.
Assess the client for medication allergies. If a contrast agent is used, the client must be assessed before the CT scan for an iodine/shellfish allergy, because the contrast agent used may be iodine based. If the client has no allergies to shellfish, then kidney function must also be evaluated, as the contrast material is cleared through the kidneys. A suitable IV line for contrast injection and a period of fasting (usually 4 hours) are required before the study. Clients who receive an IV contrast agent are monitored during and after the procedure for allergic reactions and changes in kidney function.
Which term refers to the inability to coordinate muscle movements, resulting difficulty walking? a) Agnosia b) Spasticity c) Rigidity d) Ataxia
Ataxia Ataxia is the inability to coordinate voluntary muscle action; tremors (rhythmic, involuntary movements) noted at rest or during movement suggest a problem in the anatomic areas responsible for balance and coordination. Agnosia is the loss of ability to recognize objects through a particular sensory system. Spasticity is the sustained increase in tension of a muscle when it is passively lengthened or stretched.
Lesions in the temporal lobe may result in which type of agnosia? Auditory Relationship Tactile Visual
Auditory Lesions in the temporal lobe (lateral and superior portions) may result in auditory agnosia. Lesions in the occipital lobe may result in visual agnosia. Lesions in the parietal lobe may result in tactile agnosia. Lesions in the parietal lobe (posteroinferior regions) may result in relationship and body part agnosia.
A client is scheduled for an EEG. The client inquires about any diet-related prerequisites before the EEG. Which diet-related advice should the nurse provide to the client? a) Avoid eating food for at least 8 hours before the test b) Include an increased amount of minerals in the diet c) Decrease the amount of minerals in the diet d) Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours before the test
Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours before the test The client is advised to refrain from taking sedative drugs or consuming food or drinks that contain caffeine for at least 8 hours before the test, because these may interfere with the EEG result. The client is not advised to increase or decrease the intake of minerals in the diet.
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: a) Midbrain. b) Pons. c) Medulla oblongata. d) Cerebellum.
Cerebellum. 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.
The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern? a) Client reports a piercing feeling. b) Physician maintains aseptic procedure. c) Client reports pressure relief in the head. d) Cerebrospinal fluid is cloudy in nature.
Cerebrospinal fluid is cloudy in nature. The nurse would note cloudy cerebrospinal fluid as a concern. Cloudy fluid is an indication of infection. The physician is correct to maintain aseptic procedure. A piercing feeling and pressure relief are common during and after the procedure.
Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed? a) Clonus b) Rigidity c) Flaccidity d) Ataxia
Clonus Clonus occurs when the foot is abruptly dorsiflexed. It continues to "beat" two or three times before it settles into a position of rest. Sustained clonus always indicates the present of central nervous system disease and requires further evaluation. Ataxia is incoordination of voluntary muscle action. Rigidity is an increase in muscle tone at rest characterized by increased resistance to passive movement. Flaccid posturing is usually the result of lower brain stem dysfunction the patient has no motor function, is limp, and lacks motor tone
The critical care nurse is giving end-of-shift report on a client she is caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? Normal Somnolence Stupor Comatose
Comatose The GSC is used to measure the LOC. The scale consists of three parts: eye opening response, best verbal response, and best motor response. A normal response is 15. A score of 7 or less is considered comatose. Therefore, a score of 6 indicates the client is in a state of coma and not in any other state such as stupor or somnolence. The evaluations are recorded on a graphic sheet where connecting lines show an increase or decrease in the LOC.
Which of the following is a sympathetic nervous system effect? a) Decreased peristalsis b) Constricted pupils C) Decreased blood pressure d)Constricted bronchioles
Decreased peristalsis Sympathetic effects of the nervous system include decreased peristalsis, increased blood pressure, dilated pupils, and dilated bronchioles.
A patient has a deficiency of the neurotransmitter serotonin. The nurse is aware that this deficiency can lead to: a) Parkinson's disease. b) Seizures. c) Depression. d) Myasthenia gravis.
Depression. Explanation: Serotonin helps control mood and sleep. A deficiency leads to depression.
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? a) Dysfunction of the spinal accessory nerve b) Dysfunction of the vagus nerve c) Dysfunction of the facial nerve d) Dysfunction of the acoustic nerve
Dysfunction of the vagus nerve The vagus nerve (cranial nerve X) controls the gag reflex and is tested by depressing the posterior tongue with a tongue blade. An absent gag reflex is a significant finding, indicating dysfunction of this 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? a) Administer antihistamines according to the physician's prescription b) Keep the room brightly lit and play soothing music in the background c) Help the client take a brisk walk around the testing area d) Encourage the client to drink liberal amounts of fluids
Encourage the client to drink liberal amounts of fluids The nurse should encourage the client to take liberal fluids and should inspect the injection site for swelling or hematoma. These measures help restore the volume of cerebrospinal fluid extracted. The client is administered antihistamines before a test only if he or she is allergic to contrast dye and contrast dye will be used. The room of the client who has undergone a lumbar puncture should be kept dark and quiet. The client should be encouraged to rest, because sensory stimulation tends to magnify discomfort.
A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate? Flaccidity Decorticate posturing Abnormal posture Weak muscular tone
Flaccidity The nurse would document flaccidity when the client makes no motor response to stimuli. Abnormal posturing and weak motor tone would be documented specifically as the nurse would assess. Decorticate posturing is when a client is stiff with bent arms and clenched fists with legs straight out.
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? a) Frontal lobe b) Parietal lobe c) Temporal lobe d) Occipital lobe
Frontal lobe The frontal lobe, the largest lobe, located in the front of the brain. The major functions of this lobe are concentration, abstract thought, information storage or memory, and motor function. It contains Broca's area, which is located in the left hemisphere and is critical for motor control of speech. The frontal lobe is also responsible in large part for a person's affect, judgment, personality, and inhibitions (Hickey, 2009).
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? a) Head of the bed elevated 45 degrees b) Supine with feet raised c) Prone d) Supine with the head lower than the trunk
Head of the bed elevated 45 degrees After a myelogram, positioning depends on the dye injected. When a water-soluble dye such as metrizamide is injected, the head of the bed is elevated to a 45-degree angle to slow the upward dispersion of the dye. The prone and supine positions are contraindicated when a water-soluble contrast dye is used. The client should be positioned supine with the head lower than the trunk after an air-contrast study.
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? Dystrophic Steppage Ataxic Helicopod
Helicopod A helicopod gait is an abnormal gait in which the client's feet make a half circle with each step. An ataxic gait is staggering and unsteady. In a dystrophic gait, the client waddles with the legs far apart. In a steppage gait, the feet and toes rise high off the floor and the heel comes down heavily with each step.
A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure? a) Lateral recumbent, with chin resting on flexed knees b) Supine, with the knees raised toward the chest c) Prone, with the head turned to the right d) Lateral, with right leg flexed
Lateral recumbent, with chin resting on flexed knees To maximize the space between the vertebrae, the client is placed in a lateral recumbent position with knees flexed toward the chin. The needle is inserted between L4 and L5. The other positions wouldn't allow as much space between L4 and L5.
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? a) Left frontoparietal region b) Right frontoparietal region c) Left temporal region d) Left basal ganglia
Left frontoparietal region The patient is exhibiting signs of expressive aphasia with numbness/tingling and weakness of the right arm and leg. This indicates injury to the expressive speech center (Broca's area), which is located in the inferior portion of the frontal lobe. The motor strip is located in the posterior portion of the frontal lobe. The sensory strip is located in the anterior parietal lobe.
The nurse is caring for a client after lumbar puncture. The client reports a severe headache. Which actions should the nurse complete? Select all that apply. a) Administer analgesic medication. b) Administer fluids to the client. c) Position the client in the supine position. d) Maintain the client on bed rest. e) Prepare for an epidural blood patch.
Maintain the patient on bed rest. Administer fluids to the patient. Administer analgesic medication. When the patient assumes an upright position, tension and stretching of the venous sinuses and pain-sensitive structures occur. A postpuncture headache is usually managed by bed rest, analgesic agents, and hydration. Postlumbar puncture headache may be avoided if a small-gauge needle is used and if the patient remains prone after the procedure. When more than 20 mL of the CSF is removed, the patient is positioned supine for 6 hours.
The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly? a) Gently pressing the bones on the neck b) Moving the head toward both sides c) Moving the head and chin toward the chest d) Lightly tapping the lower portion of the neck to detect sensation
Moving the head and chin toward the chest The neck is examined for stiffness or abnormal position. The presence of rigidity is assessed by moving the head and chin toward the chest. The nurse should not maneuver the neck if a head or neck injury is suspected or known. The neck should also not be maneuvered if trauma to any part of the body is evident. Moving the head toward the sides or pressing the bones on the neck will not help assess for neck rigidity correctly. While assessing for neck rigidity, sensation at the neck area is not to be assessed
The pre-nursing class is learning about the nervous system in their anatomy class. What part of the nervous system would the students learn is responsible for digesting food and eliminating body waste? a) Sympathetic b) Peripheral c) Parasympathetic d) Central
Parasympathetic The parasympathetic division of the autonomic nervous system works to conserve body energy and is partly responsible for slowing heart rate, digesting food, and eliminating body wastes.
Which lobe of the brain is responsible for spatial relationships? Parietal Occipital Temporal Frontal
Parietal The parietal lobe is essential to a person's awareness of body position in space, size and shape discrimination, and right-left orientation. The frontal lobe controls information storage or memory and motor function. The temporal lobe contains the auditory receptive area. The occipital lobe is responsible for visual interpretation.
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? a) "The blood will replace the cerebral spinal fluid that has leaked out." b) "The blood can repair damage to the spinal cord that occurred with the procedure." c) "The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid." d) "The blood provides moisture at the site, which encourages healing."
The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid. Loss of CSF causes the headache. Occasionally, if the headache persists, the epidural blood patch technique may be used. Blood is withdrawn from the antecubital vein and injected into the site of the previous puncture. The rationale is that the blood will act as a plug to seal the hole in the dura and preven further loss of CSF. The blood is not put into the subarachnoid space. The needle is inserted below the level of the spinal cord, which prevents damage to the cord. It is not a lack of moisture that prevents healing; it is more related to the size of the needle used for the puncture.
The nurse is performing a neurological assessment of a client who has sustained damage to the frontal cortex. Which of the following deficits will the nurse look for during assessment? a) The inability to maintain steady balance for the Romberg test b) Intentional tremors c) Absence of movement below the waist d) The inability to tell how a mouse and a cat are alike
The inability to tell how a mouse and a cat are alike The client with damage to the fronal cortex will display a deficit in intellectual functioning. Questions designed to assess this capacity might include the ability to recognize similarities: for example, how are a mouse and dog or pen and pencil alike? The Romberg test assesses balance, which has to do with the cerebellar and basal ganglia influence on the motor system. Absence of movement below the waist suggests a deficit with the spinal cord. Intentional tremors have to do with deficits of the motor system.
The nurse is completing the physical assessment of a patient suspected of a neurologic disorder. The patient reports to the nurse that he has recently suffered a head trauma. In such a case, which of the following precautions should the nurse take for the patient? Select all that apply. a) The nurse should make the patient sit in a chair and then assess his or her head for bleeding or swelling. b) The nurse should only move the patient's head with the help of an assistant. c) The nurse should explain the procedure of head assessment to the patient before doing the assessment. d) The nurse should not move or manipulate the patient's head while assessing for bleeding or swelling.
The nurse should not move or manipulate the patient's head while assessing for bleeding or swelling. The nurse evaluates the patient's body posture and any abnormal position of the head, neck, trunk, or extremities. The nurse carefully examines the head for bleeding, swelling, or wounds. The nurse does not move or manipulate the patient's head during physical assessment, especially if there is a recent history of trauma. The nurse should not make the patient sit on a chair or seek the help of an assistant while doing the head assessment. The nurse need not explain in detail about the procedure of head assessment to the patient.
The spinal cord is composed of 31 pairs of spinal nerves. How many pairs of thoracic nerves are contained within the spinal column? a) One b) Twelve c) Eight d) Five
Twelve There are twelve pairs of thoracic nerves, five lumbar and sacral nerves, eight cervical, and one coccygeal.
A nurse is performing a neurologic assessment on the client and notes a positive Romberg test. This test for balance is related to which of the following cranial nerves? VII III VIII X
VIII CN VIII is the acoustic nerve. It has to do with hearing, air and bone conduction, and balance. CN X is the vagus nerve and has to do with the gag reflex, laryngeal hoarseness, swallowing ability, and the symmetrical rise of the uvula and soft palate. CN III is the oculomotor and has to do with pupillary response, conjugate movements, and nystagmus. CN VII is the facial nerve and has to do with symmetry of facial movements and the ability to discriminate between the taste of sugar and salt.
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 cranial nerve: VI XI VIII II
VIII There are 12 pairs of cranial nerves. Cranial nerve VIII is the vestibulocochlear or auditory nerve responsible for hearing and balance. Cranial nerve II is the optic nerve. Cranial nerve VI is the abducens nerve responsible for eye movement. Cranial nerve XI is the accessory nerve and is involved with head and shoulder movement.
When completing a neurologic examination on a client, which question is most essential to evaluate the accuracy of the data? a) Have you experienced any unusual sensations? b) When, if any, was your last narcotic use? c) Do you have any history of forgetfulness? d) Have you been diagnosed with any mental health issues?
When, if any, was your last narcotic use? When completing a neurologic exam, it is essential to assess the use of morphine, heroin, narcotic, or central nervous system depressant because these affect the results of a neurologic examination. These types of drugs decrease the level of consciousness. The nurse can observe forgetfulness and mental status. Experiencing unusual sensations is good subjective data to have but is not essential to evaluate the accuracy of objective data.
A client is scheduled for standard EEG testing to evaluate a possible seizure disorder. Which nursing intervention should the nurse perform before the procedure? a) Maintain NPO status for 6 hours before the procedure b) Withhold anticonvulsant medications for 24 to 48 hours before the exam c) Sedate the client before the procedure, per orders d) Instruct the client that a standard EEG takes 2 hours
Withholding antiseizure medications for 24 to 48 hours prior to the exam Antiseizure 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 patient 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, the meal is not omitted, because an altered blood glucose level can cause changes in brain wave patterns. The patient is informed that the standard EEG takes 45 to 60 minutes; a sleep EEG requires 12 hours.
A nurse is preparing a client for lumbar puncture. The client has heard about post-lumbar puncture headaches and asks how to avoid having one. The nurse tells the client that these headches can be avoided by doing which of the following after the procedure? a) "Remain NPO for 6 hours." b) "Ambulate as soon as possible." c) "Remain prone for 2 to 3 hours." d) "Remain on bedrest for 3 days."
c) "Remain prone for 2 to 3 hours." he headache is caused by cerebral spinal fluid (CSF) leakage at the puncture site. The supply of CSF in the cranium is depleted so that there is not enough to cushion and stabilize the brain. When the client assumes an upright position, tension and stretching of the venous sinuses and pain-sensitive structures occur. The headache may be avoided if the client remains prone for 2 to 3 hours after the procedure. Drinking plenty of fluids will help in replacing the CSF. Hydration is important for replacement of the CSF lost so remaining NPO is not an option unless it is for other reasons, then IV fluid replacement will be important. Ambulating right away will make the possibility of a headache more likely. It is not necessary to remain on bedrest for more than a few hours, unless a headache has occurred; then bedest for overnight is usually sufficient
If a client has a lower motor neuron lesion, the nurse would expect the client to exhibit hyperactive reflexes. decreased muscle tone. muscle spasticity. no muscle atrophy.
c) Decreased muscle tone A patient with a lower motor neuron lesion would be expected to have decreased muscle tone. Those with upper motor neuron lesion would have hyperactive reflexes, no muscle atrophy, and muscle spasticity.
A nurse is working in a neurologist's office. The physician orders a Romberg test. The nurse should have the client: a) close his or her eyes and stand erect. b) close his or her eyes and jump on one foot. c) touch his or her nose with one finger. d) close his or her eyes and discriminate between dull and sharp.
close his or her eyes and stand erect. In the Romberg test, the client stands erect with the feet close together and eyes closed. If the client sways as if to fall, it is considered a positive Romberg test. All of the other options include components of neurologic tests, indicating neurologic deficits and balance.
During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates: a) cranial nerves IX and X. b) cranial nerves III and V. c) cranial nerves VI and VIII. d) cranial nerves I and II.
cranial nerves IX and X. Swallowing is a motor function of cranial nerves IX and X. Cranial nerves I, II, and VIII don't possess motor functions. The motor functions of cranial nerve III include extraocular eye movement, eyelid elevation, and pupil constriction. The motor function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement.
Lower motor neuron lesions cause a) hyperactive and abnormal reflexes. b) no muscle atrophy. c) flaccid muscles. d) increased muscle tone.
flaccid muscles Lower motor neuron lesions cause flaccid muscle paralysis, muscle atrophy, decreased muscle tone, and loss of voluntary control.
A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for: a) fever. b) visual disturbance. c) gait alteration. d) hypoxia.
hypoxia. Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing, and coughing. Therefore, the nurse should monitor the client closely for hypoxia. Temperature control, vision, and gait aren't lower brain stem functions.
The nurse is caring for a client in the emergency department with a diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the client's face and torso. The nurse would provide further instruction after seeing that the nurse aide: a) cleaned the eye area from the inner to outer eye area. b) cleaned the neck and upper chest area. c) moved the client's head to clean behind the ears. d) used mild soapy water to clean the face.
moved the client's head to clean behind the ears. Further instruction would be provided to the nurse aide when the nurse aide attempted to move the client's head to clean behind the ears. There should be no movement of the client's head when there is a history of head trauma. Cleaning the client's face with soapy water, cleaning the eye area, and cleaning the neck and upper chest are all appropriate actions completed by the nurse aide.
A client is admitted to an acute care facility for treatment of a brain tumor. When reviewing the chart, the nurse notes that the client's extremity muscle strength is rated 1/5. Which assessment finding should the nurse anticipate? a) Muscle contraction or movement is undetectable. b) Muscles move actively against gravity alone. c) Normal, full muscle strength is present. d) Muscle contraction is palpable and visible.
muscle contraction is palpable and visible Muscle strength is assessed and rated on a five-point scale in all four extremities, comparing one side to the other. A rating of 1/5 indicates palpable, visible muscle contraction on the affected side and normal, full muscle strength on the unaffected side. Normal, full muscle strength on both sides is rated 5/5. Active muscle movement against gravity alone on the affected side with normal, full muscle strength on the unaffected side is rated 3/5. Undetectable muscle contraction or movement on the affected side with normal, full muscle strength on the unaffected side is rated 0/5.
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: a) endocrine system. b) sympathetic nervous system. c) parasympathetic nervous system. d) musculoskeletal system.
sympathetic nervous system. The division of the autonomic nervous system called the sympathetic nervous system regulates the expenditure of energy. The neurotransmitters of the sympathetic nervous system are called catecholamines. During an emergency situation or an intensely stressful event, the body adjusts to deliver blood flow and oxygen to the brain, muscles, and lungs that need to react in the situation. The musculoskeletal system benefits from the sympathetic nervous system as the fight-or-flight effects pump blood to the muscles. The parasympathetic nervous system works to conserve body energy not expend it during an emergency. The endocrine system regulates metabolic processes.
