N140A Ch60 Assessment of Neurologic Function
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?
Correct response: 1+ Explanation: 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+.
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?
Correct response: Flaccidity Explanation: 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.
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?
Correct response: "It is a test for balance." Explanation: 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.
Which is a sympathetic effect of the nervous system?
Correct response: Dilated pupils Explanation: Dilated pupils are a sympathetic effect of the nervous system, whereas constricted pupils are a parasympathetic effect. Decreased blood pressure is a parasympathetic effect, whereas increased blood pressure is a sympathetic effect. Increased peristalsis is a parasympathetic effect, but decreased peristalsis is a sympathetic effect. Decreased respiratory rate is a parasympathetic effect, and increased respiratory rate is a sympathetic effect.
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?
Correct response: Dysfunction of the vagus nerve Explanation: 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.
Which of the following areas of the brain are responsible for temperature regulation?
Correct response: Hypothalamus Explanation: The hypothalamus also controls and regulates the autonomic nervous system and maintains temperature by promoting vasoconstriction or vasodilation. The thalamus acts primarily as a relay station for all sensation except smell. The medulla and pons are essential for respiratory function.
A patient has been diagnosed with damage to Broca's area of the left frontal lobe. To document the extent of damage, the nurse would assess the patient's:
Correct response: Speech. Explanation: The motor strip, which lies in the frontal lobe, anterior to the central sulcus, is responsible for muscle movement. It also contains Broca's area (left frontal lobe region in most people), critical for motor control of speech.
The spinal cord is composed of 31 pairs of spinal nerves. How many pairs of thoracic nerves are contained within the spinal column?
Correct response: Twelve Explanation: There are twelve pairs of thoracic nerves, five lumbar and sacral nerves, eight cervical, and one coccygeal.
A nurse is completing a neurological assessment and determines that the client has significant visual deficits. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit?
Correct response: occipital Explanation: The vision center is located in the occipital lobe. There is little that may interfere with the visual process in the other lobes of the brain.
Which term refers to the inability to coordinate muscle movements, resulting difficulty walking?
Correct response: Ataxia Explanation: 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.
Which term refers to a method of recording, in graphic form, the electrical activity of a muscle?
Correct response: Electromyography Explanation: 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 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?
Correct response: Encourage the client to drink liberal amounts of fluids Explanation: 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 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?
Correct response: Frontal lobe Explanation: 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 client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?
Correct response: Occipital Explanation: The occipital lobe is responsible for interpreting visual stimuli. The frontal lobe influences personality, judgment, abstract reasoning, social behavior, language expression, and movement. The temporal lobe controls hearing, language comprehension, and storage and memory recall (although memory recall is also stored throughout the brain). The parietal lobe interprets and integrates sensations, including pain, temperature, and touch; it also interprets size, shape, distance, and texture.
The brain stem holds the medulla oblongata. What is the function of the medulla oblongata?
Correct response: Transmits motor impulses from the brain to the spinal cord Explanation: The medulla oblongata lies below the pons and transmits motor impulses from the brain to the spinal cord and sensory impulses from peripheral sensory neurons to the brain. The medulla contains vital centers concerned with respiration, heartbeat, and vasomotor activity (the control of smooth muscle activity in blood vessel walls).
The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply.
Correct response: Unequal pupils Pinpoint pupils Absence of pupillary response Explanation: Normal assessment findings includes that the pupils are equal and reactive to light. Pupils that are unequal, pinpoint in nature, or fail to respond indicate a neurologic impairment.
A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with:
Correct response: body temperature control. Explanation: 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.
The nurse has completed evaluating the client's cranial nerves. The nurse documents impairment of the right cervical nerves (CN IX and CN X). Based on these findings, the nurse should instruct the client to
Correct response: refrain from eating or drinking for now. Explanation: Significant findings of CN IX (glossopharyngeal) include difficulty swallowing (dysphagia) and impaired taste, and significant findings of CN X (vagus) include weak or absent gag reflex, difficulty swallowing, aspiration, hoarseness, and slurred speech (dysarthria). Based on these findings, the nurse should instruct the client to refrain from eating and drinking and should contact the health care provider. The other instructions are associated with abnormalities of CN II (optic) and CN VIII (acoustic).
A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in
Correct response: thought content. Explanation: Hallucinations are disturbances of thought content. They are not disturbances in motor ability, intellectual function, or emotional status.
