Care for clients with neurologic disorders

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?

"It is a test for balance." 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.

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 The GCS is a numeric scale with a maximum score of 15. A score of 7 or less is considered a coma .

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 Parkinson disease develops from decreased availability of dopamine, not acetylcholine, epinephrine, or serotonin.

A nurse is caring for a client diagnosed with Ménière disease. While completing a neurologic examination on the client, the nurse assesses cranial nerve VIII. The nurse would be correct in identifying the function of this nerve as what?

Hearing and equilibrium Cranial nerve VIII (acoustic) is responsible for hearing and equilibrium. Cranial nerve XII (hypoglossal) is responsible for movement of the tongue. Cranial nerve II (optic) is responsible for visual acuity and visual fields. Cranial nerve I (olfactory) functions in sense of smell.

The nurse is caring for a client with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the client's neurologic assessment?

Loss of voluntary control of movement Upper motor neuron lesions do not cause muscle atrophy, flaccid paralysis, or slow reflexes. However, upper motor neuron lesions normally cause loss of voluntary control.

Which cerebral lobe contains the auditory receptive areas?

Temporal The temporal lobe plays the most dominant role of any area of the cortex in cerebration. The frontal lobe, the largest lobe, controls concentration, abstract thought, information storage or memory, and motor function. The parietal lobe contains the primary sensory cortex, which analyzes sensory information and relays interpretation to the thalamus and other cortical areas. The occipital lobe is responsible for visual interpretation.

A client is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the client in preparation for this test?

You will need to lie still throughout the procedure Preparation for CT scanning includes teaching the client about the need to lie quietly throughout the procedure. If the client were having an MRI, metal and noise would be appropriate teaching topics. There is no need to fast prior to a CT scan of the brain.

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 Glasgow Come Scale (GCS) score is based on three patient responses: eye opening, motor response, and verbal response. The patient receives a score for his best response in each area, and the three scores are added together. The total score will range from 3 to 15; the higher the number, the better. A score of 8 or lower usually indicates coma.

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

"Who is the president of the United States?" Assessing orientation to time, place, and person assists in evaluating mental status. Does the client know what day it is, what year it is, and the name of the president of the United States? Is the client aware of where he or she is? Is the client aware of who the examiner is and why he or she is in the room? "Can you write your name on this piece of paper?" will assess language ability. "Can you count backward from 100?" assesses the client's intellectual function. "Are you having hallucinations?" assesses the client's thought content.

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 Parasympathetic stimulation results in constricted pupils, constricted bronchioles, increased peristaltic movement, and contracted muscular walls of the urinary bladder.

A client in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is which of the following?

Hypothalamus The hypothalamus plays an important role in the endocrine system because it regulates the pituitary secretion of hormones that influence metabolism, reproduction, stress response, and urine production. It works with the pituitary to maintain fluid balance through hormonal release and maintains temperature regulation by promoting vasoconstriction or vasodilatation. The cerebellum, thalamus, and midbrain are not directly involved in temperature regulation.

A client has undergone a lumbar puncture for a neurological assessment. The client is put under the post-procedure care of a nurse. Which important post-procedure nursing interventions should be performed to ensure maximum comfort for the client? Select all that apply.

Position the client flat for at least three hours or as directed by the physician. Encourage a liberal fluid intake for the client. The nurse should encourage the client to take liberal fluids and inspect the injection site for swelling or hematoma.

A nurse conducts the Romberg test on a client by asking the client to stand with the feet close together and the eyes closed. As a result of this posture, the client suddenly sways to one side and is about to fall when the nurse intervenes and saves the client from being injured. How should the nurse interpret the client's result?

Positive Romberg test, indicating a problem with equilibrium If the client sways and starts to fall during the Romberg test, it indicates a positive result. This means the client has a problem with equilibrium. The examiner or the nurse stands fairly close to the client during the test to prevent the client from falling. The Romberg test is used to assess the client's motor function, including muscle movement, size, tone, strength, and coordination. However, the Romberg test is not used to assess the client's level of consciousness, body mass, or vision.

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 Reduction in cerebral blood flow (CBF) is a change that occurs in the normal aging process. Deep tendon reflexes can be decreased or, in some cases, absent. Cerebral metabolism decreases as the client advances in age. Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used.

The brain is a complex structure and is divided into three parts: the cerebrum, the cerebellum, and the brain stem. The cerebrum is divided into two hemispheres and is further divided into four lobes per hemisphere. Which section of the brain controls and coordinates muscle movements?

cerebellum The cerebellum, which is located behind and below the cerebrum, controls and coordinates muscle movement.

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 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. Reference:

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. 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.

Which cerebral lobes is the largest and controls abstract thought?

Frontal The frontal lobe also controls information storage or memory and motor function. The temporal lobe contains the auditory receptive area. The parietal lobe contains the primary sensory cortex, which analyzes sensory information and relays interpretation to the thalamus and other cortical areas. The occipital lobe is responsible for visual interpretation.

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." Lower motor neuron lesions cause flaccid muscle paralysis, muscle atrophy, decreased muscle tone, and loss of voluntary control.

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?

"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).

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!"

A nurse is preparing a client for a computed tomography (CT) scan that requires infusion of radiopaque dye. Which question is the most important for the nurse to ask?

Are you allergic to seafood or iodine?" Seafood and the radiopaque dye used in CT contain iodine. To prevent an allergic reaction to the radiopaque dye, the nurse should ask the client about allergies to seafood or iodine before the CT scan. Because fasting is unnecessary before a CT scan, the nurse doesn't need to obtain information about the client's last food and fluid intake. The client's last dose of medication and current weight also are irrelevant.

A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first?

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 iodine, 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.

A client exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most plausible cause of this client's health problem?

Cerebellar dysfunction The cerebellum controls fine movement, balance, position sense, and integration of sensory input. Portions of the pons control the heart, respiration, and blood pressure. Cranial nerves IX to XII connect to the brain in the medulla. Cranial nerves III and IV originate in the midbrain.

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 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 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?

Occipital 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.

A client with lower back pain is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should prioritize what action?

Positioning the client with the head of the bed elevated 45 degrees After myelography, the client lies in bed with the head of the bed elevated 30 to 45 degrees. The client is advised to remain in bed in the recommended position for 3 hours or as prescribed. Drinking liberal amounts of fluid for rehydration and replacement of CSF may decrease the incidence of post-lumbar puncture headache. Deep breathing and coughing exercises are not normally necessary since there is no consequent risk of atelectasis.

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: cranial nerves IX and X. cranial nerves I and II. cranial nerves III and V. cranial nerves VI and VIII.

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.

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 CSF pressure with the patient in a lateral recumbent position is normally 70 to 200 mm H2O. Pressures of more than 200 mm H2O are considered abnormal.

A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Of the two illustrations of posturing shown, which demonstrates a more severe dysfunction?

B Both decerebrate posturing and decorticate posturing indicate serious brain injury. Decerebrate posturing (B) involves extreme extension of the upper and lower extremities and indicates severe damage at the lower midbrain and upper pons. Decerebrate posturing has a worse prognosis than does decorticate posturing (A), which involves abnormal flexion of the upper extremities and extension of the lower extremities and indicates damage to the upper midbrain. Flaccidity, the absence of motor response, indicates the most severe neurologic impairment.

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 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).

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. Cranial nerve I is the olfactory nerve. The client's sense of smell could be assessed by asking him or her to identify common odors. Assessment of papillary reflex does not address the olfactory function of cranial nerve I. The Snellen chart would be used to assess cranial nerve II (optic).

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 medulla oblongata contains vital centers concerned with respiration, heartbeat, and vasomotor activity (the control of smooth muscle activity in blood vessel walls).