Med Surg II: Chapter 38 - Assessment of the Nervous System

A diabetic client is scheduled to have a computed tomography-positron emission tomography scan to rule out a brain tumor. What health teaching would the nurse include? A. "Take your antidiabetic medications as usual before the test." B. "This test will only take about 20 to 30 minutes to complete." C. "You'll need to let you doctor know if you have seafood allergies." D. "You may drink liquids up until an hour before the test."

A. "Take your antidiabetic medications as usual before the test." The test requires the client to be NPO for at least 4 hours before the test, but the client should take any prescribed antidiabetic drugs as usual. The test takes between 2 and 3 hours after the client receives an isotope. This contrast medium is safe for clients who have allergies to seafood.

The nurse is caring for a client who is scheduled to have a transcranial Doppler (TCD). What does this diagnostic test evaluate? A. Cerebral vasospasm B. Intracranial pressure C. Cerebrospinal fluid D. Evoked potentials

A. Cerebral vasospasm A transcranial Doppler (TCD) is used to evaluate cerebral vasospasm or narrowing of arteries. It is noninvasive. Cerebrospinal fluid is obtained and measured during a lumbar puncture (LP). Evoked potentials measure the electrical signals in the brain during an EEG. Intracranial pressure is a measurement of blood, brain tissue, and cerebral spinal fluid and is not measured by TCD.

The nurse is performing a neurologic assessment on an 81-year-old client. Which physiologic change does the nurse expect to find because of the client's age? A. Decreased coordination B. Increased touch sensation C. Nightly confusion D. Increased sleeping during the night

A. Decreased coordination When performing a neurologic assessment on an elderly client, the nurse expects to find decreased coordination. Older adults experience decreased coordination as a result of the aging process. Older adults frequently go to bed earlier and arise earlier than younger adults. Sensation to touch is decreased, not increased. Nightly confusion, sometimes referred to as "sundowning," is not an expected change with all older adults.

The nurse is assessing a client for cerebellar function. Which assessments will the nurse perform? Select all that apply. A. Gait pattern B. Muscle strength C. Coordination D. Sensation E. Speech and language

A. Gait pattern C. Coordination The cerebellum controls gait, equilibrium, and coordination ability. Muscle strength and speech are functions of the motor strip and Broca area of the frontal lobe of the brain. The sensory strip is located in the parietal lobe.

The nurse is preparing a client for cerebral angiography. Which nursing actions areappropriate as part of care for the client? (Select all that apply.) Select all that apply. A. Hold any drug that can interfere with kidney function. B. Communicate any reaction to iodinated contrast to the primary health care provider. C. Check for a history of acute or chronic kidney disease. D. Provide adequate hydration before and after the diagnostic test. E. Ask about the client's history of any and all allergies.

A. Hold any drug that can interfere with kidney function. B. Communicate any reaction to iodinated contrast to the primary health care provider. C. Check for a history of acute or chronic kidney disease. D. Provide adequate hydration before and after the diagnostic test. E. Ask about the client's history of any and all allergies. The care for the client involves all of these important nursing actions. The client needs adequate hydration to prevent kidney damage from the contrast medium. The nurse ensures that any client allergies are reported to the primary health care provider.

The nurse is assessing a client who is drowsy but easily awakened. What level of consciousness (LOC) would the nurse document for this client? A. Lethargic B. Stuporous C. Alert D. Comatose

A. Lethargic The client is not alert and awake but can easily be awakened, which is referred to aslethargy. Clients who are stuporous can only be aroused with painful stimuli. Comatose clients cannot be aroused.

The nurse is caring for a client who had a lumbar puncture. What priority action would the nurse perform to ensure client safety? A. Monitor for increased intracranial pressure, such as decreased level of consciousness (LOC). B. Observe the needle insertion site for cerebrospinal fluid (CSF) leakage or infection. C. Give an analgesic for client report of a headache if it is moderate or severe. D. Take vital signs every hour after the procedure until the client is stable.

A. Monitor for increased intracranial pressure, such as decreased level of consciousness (LOC). After a lumbar puncture, the client has less CSF which can cause an expected mild to moderate headache. However, the client may experience increased intracranial pressure which is manifested by decreasing LOC, severe headache, nausea, and vomiting. The nurse monitors for these potentially life-threatening changes. The nurse also monitors for CSF leakage, takes vital signs as per agency protocol, and provides analgesia as needed. However, these actions are not the priority for the nurse at this time.

The nurse is performing a neurologic assessment for a client and suspects damage to the client's brainstem. Which assessment findings are consistent with brainstem involvement? (Select all that apply.) Select all that apply. A. Pupil constriction B. Dysrhythmias C. Aphasia D. Irregular respiratory pattern E. Dysphagia

A. Pupil constriction B. Dysrhythmias D. Irregular respiratory pattern E. Dysphagia The brainstem is comprised of the medulla, pons, and midbrain. The nuclei of the cranial nerves that control vital signs (CN X) and swallowing (CN IX-XII) are located in the pons and medulla. CN X (vagus nerve) also controls cardiac and breathing functions. The nuclei of the oculomotor nerve (CN III) causes pupil reaction. When the nerve is damaged, the pupils constrict. Aphasia occurs when the speech and/or language centers in the cerebrum are affected.

The nurse is assessing a client with a neurologic condition who is reporting difficulty chewing when eating. The nurse suspects that which cranial nerve has been affected? A. Trigeminal (CN V) B. Trochlear (CN IV) C. Abducens (CN VI) D. Facial (CN VII)

A. Trigeminal (CN V) The nurse suspects that the trigeminal cranial nerve is affected when a client complains of difficulty chewing when eating. The trigeminal nerve affects the muscles of mastication.The abducens nerve affects eye movement via lateral rectus muscles. The facial nerve affects pain and temperature from the ear area, deep sensations in the face, and taste in the anterior two-thirds of the tongue. The trochlear nerve affects eye movement via superior oblique muscles.

A client has just returned from having cerebral angiography. Which assessment finding would lead the nurse to act immediately? A. Severe headache B. Bleeding C. Urge to void D. Increased temperature

B. Bleeding After a cerebral angiography, the nurse would immediately react if the client had any bleeding. If bleeding is present at the puncture site, manual pressure on the site is maintained along with immediate notification of the primary health care provider. Increased temperature or the urge to void is not typical complications of cerebral angiography. Severe headache is a typical complication of a lumbar puncture, but not of cerebral angiography.

The nurse is caring for a client with impaired vision. The nurse knows the cranial nerve that controls visual acuity is which of the following? A. Cranial nerve V (trigeminal) B. Cranial nerve II (optic) C. Cranial nerve III (oculomotor) D. Cranial nerve VII (facial)

B. Cranial nerve II (optic) Cranial nerve II (optic) is responsible for vision and cranial nerve III (oculomotor) is responsible for eye movement. Cranial nerve V (trigeminal) allows an individual to feel a light breeze on the face. This nerve is responsible for sensation from the skin of the face and scalp and the mucous membranes of the mouth and nose.Cranial nerve VII (facial) is responsible for pain and temperature from the ear area, deep sensations from the face, and taste from the anterior two-thirds of the tongue.

Which client diagnosed with neurologic injury is typically at highest risk for depression? A. Older man with a mild stroke B. Young man with a spinal cord injury C. Older woman with a seizure D. Young woman with a minor closed head injury

B. Young man with a spinal cord injury A young man with a spinal cord injury is at highest risk for depression. Although each individual responds differently, young adults who experience a spinal cord injury and loss of independent movement are more likely to experience depression. Keeping in mind people's differences in personal experiences, the client with a mild stroke without long-term deficits, the client who had a seizure or the young woman who sustained a minor head injury are generally at a lower risk of depression.

A client is scheduled for an electroencephalogram (EEG). Which instruction does the nurse give the client before the test? A. "You may bring some music to listen to for distraction." B. "Please do not have anything to eat or drink after midnight." C. "Do not take any sedatives 12 to 24 hours before the test." D. "You will need to have someone to drive you home."

C. "Do not take any sedatives 12 to 24 hours before the test." Before an EEG, the client needs to be instructed not to use sedatives or stimulants for 12 to 24 hours prior to the test. A client would not fast prior to an EEG as hypoglycemia may alter results. Testing takes place in a quiet room, so music for distraction is not appropriate. Unless the EEG is for sleep disorder diagnosis, the client will not need to be driven home.

The nurse is performing a rapid neurologic assessment on a trauma client. Which assessment findings are considered normal? (Select all that apply.) Select all that apply. A. Decerebrate posturing B. Lethargy C. Glasgow Coma Score (GCS) 15 D. Minimal response to stimulation E. Pupil constriction to light

C. Glasgow Coma Score (GCS) 15 E. Pupil constriction to light Normal rapid neurologic assessment findings include a GCS (Glasgow Coma Score) of 15 and pupil constriction to light. The GCS range is between 3 and 15. Pupil constriction is a function of cranial nerve III. The pupils would be equal in size and round and regular in shape and would react to light and accommodation (PERRLA).Decerebrate or decorticate posturing is not normal, as well as pinpoint or dilated and nonreactive pupils. Both of findings are a late sign of neurologic deterioration. In addition, minimal response to stimulation and increased lethargy are not normal findings.

The nurse is assessing a military veteran who reports frequent headaches. For which neurologic health problem is the client most at risk? A. Brain cancer B. Bell palsy C. Traumatic brain injury D. Stroke

C. Traumatic brain injury Military veterans are most at risk for traumatic brain injury (TBI) due to explosions that many experienced during wars. Signs and symptoms of TBI can be mild such as headache or memory loss or more severe.

The nurse has just received report on a group of clients on the neurosurgical unit. Which client is the nurse's first priority? A. Client who consistently demonstrates decortication when stimulated. B. Client whose deep tendon reflexes have become hyperactive. C. Client who displays plantar flexion when the bottom of the foot is stroked. D. Client whose Glasgow Coma Scale (GCS) has changed from 15 to 13.

D. Client whose Glasgow Coma Scale (GCS) has changed from 15 to 13. After receiving report on a group of clients, the nurse's first priority is to assess the client whose GCS has changed from 15 to 13. A decrease of two or more points in the Glasgow Coma Scale total is clinically significant and indicates a major change in neurologic status. This finding must be reported immediately to the primary health care provider (PHCP).The client with hyperactive reflexes, the client displaying plantar flexion when the bottom of the foot is stroked, and the client with decortication upon stimulation will need to be assessed, but they do not require immediate attention.

Which information is most important for the nurse to communicate to the primary health care provider about a client who is scheduled for CT angiography? A. Allergy to penicillin B. History of bacterial meningitis C. The client's dose of metformin (Glucophage) held today D. Poor skin turgor and dry mucous membranes

D. Poor skin turgor and dry mucous membranes The most important information for the nurse to communicate to the PCP about a client scheduled for a CT angiography is the client with poor skin turgor and dry mucous membranes. This assessment indicates dehydration which places the client at risk for contrast-induced nephropathy. Allergy to penicillin, history of bacterial meningitis, and withheld metformin will need to be reported as part of the client hand-off to radiology.