Hinkle Chapter 65: Assessment of Neurologic Function
To evaluate a client's cerebellar function, a nurse should ask
"Do you have any problems with balance?"
How many pairs of coccygeal nerves are contained within the spinal column?
1
How many pairs of thoracic nerves are contained within the spinal column?
12
How many pairs of lumbar and sacral nerves are contained within the spinal column?
5
When more than 20 mL of CSF is removed during a lumbar puncture, the patient is positioned supine for
6 hours
How many pairs of cervical nerves are contained within the spinal column?
8
What is performed to obtain samples of CSF from the subarachnoid space for laboratory examination and to measure CSF pressure
A lumbar puncture (spinal tap)
What major transmitter of the parasympathetic nervous system stimulates the vagal nerve to slow the heart rate?
Acetylcholine
Which neurotransmitter is deficient in myasthenia gravis?
Acetylcholine
The nurse evaluates motor response in a comatose or unconscious client by
Administering a painful stimulus
This term refers to the inability to recognize objects through a particular sensory system
Agnosia
The term that refers to a client's inability to identify a familiar object by touch after head injury to the parietal lobe
Astereognosis
This term refers to the inability to coordinate muscle movements, resulting in difficulty walking
Ataxia
Lesions in the temporal lobe may result in this type of agnosia
Auditory
A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with
Body Temperature Control
What portion of the brain is most likely to cause an inability to breathe?
Brain Stem
The cause of post-lumbar puncture headaches
Cerebral spinal fluid leakage at the puncture site
What is it called when reflexes are hyperactive when the foot is abruptly dorsiflexed
Clonus
What does the nurse recognize as a parasympathetic effect when assessing the pupils of a patient who has had a head injury?
Constricted pupils
This neurotransmitter inhibits pain transmission
Enkephalin
The trochlear nerve (IV) controls which function?
Eye muscle movement
What would the nurse document when the client makes no motor response to stimuli?
Flaccidity
This lobe of the brain is responsible for concentration and abstract thought
Frontal
Which lobe affects personality and affect?
Frontal
Cranial nerve IX is also known as
Glossopharyngeal
Term to describe when a client's feet make a half circle during ambulation
Helicopod
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:
Hypoxia
Which cranial nerve effects smell?
I or Olfactory
Which cranial nerve is the nurse assessing when they ask the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint?
I or Olfactory
Which cranial nerve is the nurse testing when using the Snellen eye chart?
II or Optic
What cranial nerve is affected with decreased visual fields?
II or optic
Extraocular eye movement, eyelid elevation, and pupil constriction are functions of this cranial nerve
III or Oculomotor
The nurse should instruct the client to refrain from eating and drinking with impairment of these 2 nerves
IX or Glossopharyngeal and X or Vagus
To determine when the client is ready for a liquid diet, the nurse assesses cranial nerves
IX or Glossopharyngeal and X or Vagus
Swallowing is a motor function of Which cranial nerves?
IX or Glossopharyngeal and X or the vagus
Upper motor neuron lesions cause
Increased muscle tone, hyperactive and abnormal reflexes
The patient is exhibiting signs of expressive aphasia with numbness/tingling and weakness of the right arm and leg
Left frontoparietal region (Broca's area)
This structure of the brain transmits motor impulses from the brain to the spinal cord, and sensory impulses from the peripheral sensory neurons to the brain
Medulla oblongata
client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?
Midbrain
How does the nurse assess a patient for neck rigidity correctly?
Moving the head and chin toward the chest
This lobe contains your primary visual cortex
Occipital
The cerebral cortex is located
On the surface of the cerebrum
This lobe analyzes sensory information such as pressure, vibration, pain, and temperature and is responsible for spatial relationships
Parietal
This lobe is the primary sensory cortex. It is essential to a person's awareness of his body in space, as well as orientation in space and spatial relations.
Parietal
What disorder caused by a lesion in the basal ganglia?
Parkinson's Disease
The priority nursing intervention that should be provided after a lumbar puncture
Position the client flat for at least 3 hours
A patient is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position?
Semi fowlers
A patient has been diagnosed with damage to Broca's area of the left frontal lobe. What would the nurse assess to document the extent of the damage?
Speech
Which nervous system regulates the expenditure of energy?
Sympathetic
This lobe contains the auditory receptive areas located around the temples
Temporal
This test measures the hearing acuity precisely
The Audiometric test
These tests help to identify types of hearing loss
The Rinne test and the Weber test
This test is used to evaluate a person's ability to sustain balance
The Romberg test - close eyes and stand erect
This part of the brain is largely responsible for coordination of all movement
The cerebellum
Reflexes in the body are centered in
The spinal cord
What is the function of the medulla oblongata?
Transmits motor impulses from the brain to the spinal cord
Chewing is a function of which cranial nerve?
V or Trigeminal
The patient is experiencing difficulty chewing. Which cranial nerve does this indicate damage to?
V or Trigeminal
This cranial nerve innervates the forehead, cheeks, and jaw
V or Trigeminal
What cranial nerve does the nurse understand can cause facial pain?
V or Trigeminal
Incurring damage to which cranial nerve can cause episodes of double vision?
VI or Abducens
Which cranial nerve controls lateral eye movement?
VI or Abducens
This cranial nerve affects symmetry of facial expression and muscle movement in the face, along with salivation and tearing, taste, and sensation in the ear.
VII or Facial
The Romberg test is related to cranial nerve
VIII or Acoustic
The whisper test is used to assess which cranial nerve?
VIII or Acoustic
This cranial nerve is tested by listening to a ticking watch
VIII or Acoustic
Damage to which cranial nerve results in loss of gag reflex?
X or Vagus
Having the client say "ah" tests which cranial nerve?
X or the vagus nerve
This cranial nerve allows you to shrug your shoulders and turn your head against resistance
XI or Spinal accessory
When asking a patient to stick out their tongue, which cranial nerve are you evaluating?
XII or Hypoglossal
Which diagnostic test does the nurse anticipate to monitor the status of a cerebral aneurysm?
cerebral angiography
During an acute crisis, the nurse should check which reflex response to rapidly assess brain stem function
corneal reflex response
Lower motor neuron lesions cause
flaccidity, muscle atrophy, decreased muscle tone, and loss of voluntary control
To assess the function of cranial nerve XII (hypoglossal), the nurse should assess the client's ability to
stick out the tongue and move it rapidly from side to side and in and out.