Bre Neuro Prepu

The nurse is admitting a client to the unit who is diagnosed with a lower motor neuron lesion. What entry in the client's electronic record is most consistent with this diagnosis?

"Client demonstrates an absence of deep tendon reflexes.

A client has been exhibiting neurological symptoms for several weeks and the neurologist is admitting the client to the hospital for extensive testing. Since diagnostics have not yet revealed the cause of the symptoms, which client statement would indicate the need for further client education?

"It's good to know the continual tingling in my fingers and toes is not connected with my nervous system!"

The nurse is assessing the client's mental status . Which question will the nurse include in the assessment?

"Who is the president of the United States?"

The Glasgow Coma Scale is a common screening tool used for patients with a head injury. During the physical exam, the nurse documents that the patient is able to spontaneously open her eyes, obey verbal commands, and is oriented. The nurse records the highest score of:

15

A nurse notes on the electronic medical record of a post-lumbar puncture patient an abnormal CSF value. Which of the following is the minimal level that is an abnormal value?

210 mm H2O

The nurse is scoring the client's level of consciousness using the Glasgow Coma Scale. Which score would indicate that the client is in comatose state

7

Which cranial nerve is tested by listening to a ticking watch?

Acoustic

The nurse caring for an 80-year-old client knows that the client has a preexisting history of dulled tactile sensation. The nurse should first consider what possible cause for this client's diminished tactile sensation?

Age-related neurologic changes

The nurse reviews the physician's emergency department progress notes for the client who sustained a head injury and sees that the physician observed the Battle sign. The nurse knows that the physician observed which clinical manifestation?

An area of bruising over the mastoid bone

The nurse is caring for a client with a traumatic brain injury. Which assessment findings indicate to the nurse that the client is developing Cushing's reflex? Select all that apply.

Apical pulse is 42 beats per minute, Blood pressure is 140/38 mmHg, Systolic blood pressure is 180 mm/Hg

The nurse is performing a neurologic assessment of a client whose injuries have rendered the client unable to follow verbal commands. How should the nurse proceed with assessing the client's level of consciousness (LOC)?

Assess the client's eye opening and response to stimuli

A nurse has received an unconscious client with a traumatic brain injury (TBI). The nurse is concerned about the client's skin integrity and implements interventions to prevent pressure injuries. Which action should the nurse implement during the shift?

Assessing all body surfaces and documenting skin integrity every 8 hours

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client?

Bradycardia and hypertension

The nurse responds to the call light of a client who has had a cervical discectomy earlier in the day. The client states that she is having severe pain that had a sudden onset. What is the nurse's most appropriate action?

Call the surgeon to report the client's pain.

A client is being given a medication that stimulates the parasympathetic system. Following administration of this medication, the nurse should anticipate what effect?

Constricted pupils

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?

Decorticate

The nurse is planning the care of a client with Parkinson disease. The nurse should be aware that treatment will focus on what pathophysiologic phenomenon?

Decreased availability of dopamine

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?

Encourage the client to drink liberal amounts of fluids

Which cerebral lobes is the largest and controls abstract thought?

Frontal

A client is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this client, the nurse has the client stick out the tongue and move it back and forth. What is the nurse assessing?

Function of the hypoglossal nerve

A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution?

Hot or cold packs

A client is brought to the ED by family after falling off the roof. The care team suspects an epidural hematoma, prompting the nurse to anticipate for which priority intervention?

Making openings in the skull

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?

Monitoring the patency of an indwelling urinary catheter

In the course of a focused neurologic assessment, the nurse is palpating the client's major muscle groups at rest and during passive movement. Data gleaned from this assessment will allow the nurse to describe which of the following aspects of neurologic function?

Muscle tone

A patient is brought to the emergency room following a motor vehicle accident in which she sustained a head trauma. The patient is complaining of blindness in her left eye. The nurse would be correct in suspecting that this sensory deficit is related to damage in what cerebral lobe?

Occipital

Which cranial nerve is responsible for muscles that move the eye and lids?

Oculomotor

The nurse is doing an initial assessment on a client newly admitted to the unit with a diagnosis of cerebrovascular disease. The client has difficulty copying a figure that the nurse has drawn and is diagnosed with visual receptive aphasia. What brain region is primarily involved in this client's deficit?

Parietal-occipital area

When assessing a 36-year-old male, the nurse gently strokes the client's right palm using a cotton applicator. As the nurse strokes the client's palm the nurse then checks to see if the client will begin to grasp the applicator. This assessment is associated with which of the following reflexes?

Pathologic

The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action?

Prepare for interventions to increase the client's BP.

Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition?

Raise the head of the bed and place the patient in a sitting position.

A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-related changes that may influence the assessment results. Of what phenomenon should the nurse be aware?

Reduction in cerebral blood flow

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?

The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid.

A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the client's current health status is most likely to have precipitated this event?

The client's urinary catheter became occluded.

A patient has been brought to the emergency department (ED) with signs and symptoms of a stroke and a stat computed tomography (CT) head scan has been ordered. The ED nurse should know that the image that results from CT indicates distinguishing differences based on which of the following variables?

Variations in tissue density

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?

Widened pulse pressure

A client's family is trying to understand the client's diagnosis of an acute subdural hematoma. The nurse would best explain the condition by stating that a subdural hematoma is:

a result of venous bleeding into the space below the dura.

A client is currently being stimulated by the parasympathetic nervous system. What effect will this nervous stimulation have on the client's bladder?

bladder contract

A nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a 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?

comatose

When the nurse observes that the client has extension and external rotation of the arms and wrists and plantar flexion of the feet, the nurse records the client's posture as

decerebrate

Which is a sympathetic effect of the nervous system?

dilated pupils

The nurse is caring for a post-lumbar puncture client who is experiencing an intense headache. If the physician chooses aggressive treatment, which nursing action is anticipated

drawing venous blood to perform a blood patch

A trauma client in the ICU has been declared brain dead. What diagnostic test is used in making the best determination that the brain's electrical activity has ceased?

eeg

A typical spinal cord functions as a "highway" for sensory and descending motor neurons, providing conduction of impulses to and from the brain. The spinal cord is surrounded and protected by bony vertebrae, and ends between the:

first and second lumbar vertebrae

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?

frontal lobe

The sympathetic and parasympathetic nervous systems have a direct effect on the circulatory system. Stimulation of the parasympathetic nervous system (PNS) causes which of the following?

heartrate to decrease

A client presents to the emergency department status postseizure. The physician wants to know what the pressure is in the client's head. What test might be ordered on this client?

lumbar puncture

The brain is a complex structure and is divided into three parts: the cerebrum, the cerebellum, and the brain stem. The brain stem consists of the midbrain, pons, and medulla oblongata. Which part of the brain contains regulatory centers for heartbeat, vasomotor activity, and breathing?

medulla oblongata

The family nurse practitioner 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?

moving the head and chin toward the chest

The nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response?

observing the client's response to painful stimulus

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?

occipital

A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in

thought content.

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI?

young age, male gender, alcohol/drug use

To help assess a client's cerebral function, a nurse should ask:

"Have you noticed a change in your memory?"

What neurologic assessment should the nurse perform to gauge the client's function of cranial nerve I?

Have the client identify familiar odors with the eyes closed

The nurse is scoring the client's level of consciousness using the Glasgow Coma Scale. Which score would indicate that the client is in comatose state?

7

An older adult client is being discharged home. The client lives alone and has atrophy of the olfactory organs. The nurse tells the client's family that it is essential that the client have what installed in the home?

A smoke detector

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best?

Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes.

The nurse is caring for a client whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be prescribed to control this?

Baclofen

A nurse is planning discharge education for a client who underwent a cervical discectomy. What strategies would the nurse assess that would aid in planning discharge teaching?

Care of the cervical collar

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:

Cerebellum

Which of the following areas of the brain are responsible for temperature regulation?

Hypothalamus

A neurological nurse is conducting a focused neurological assessment of a patient who has just been admitted to the rehabilitative facility. During this assessment, the nurse has asked the patient to swallow and has tested the patient's gag reflex with a tongue depressor. These assessments test the function of which of the patient's cranial nerves?

IX (glossopharyngeal) and X (vagus)

The nurse caring for a client with a spinal cord injury notes that the client is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action?

Increase the frequency of ROM exercises.

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client?

Ineffective airway clearance related to brain injury

A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require?

The patient will be able to ambulate independently.

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

refrain from eating or drinking for now

A 35-year-old client is being admitted to the intensive care unit (ICU) for increased observation with a brain injury and is awake, alert, and disoriented to time and situation. The client sustained a fall from a roof, and x-rays are pending. The nurse would anticipate which supportive priority measures for this client?

Cervical and spinal immobilization

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?

Dysfunction of the vagus nerve

Which safety action will the nurse implement for a client receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)?

Ensure that no client care equipment containing metal enters the room where the MRI table is located.

A client is admitted reporting low back pain. How will the nurse best determine if the pain is related to a herniated lumbar disc?

Have the client lie on the back and lift the leg, keeping it straight.