Ch 65 med surg 2
The nurse is preparing the patient for a diagnostic test to evaluate blood flow within intracranial blood vessels. For which of the following tests is the nurse preparing for the patient? a) Transcranial Doppler b) MRI c) Cerebral angiography d) CT
a) Transcranial Doppler Explanation: Transcranial Doppler flow studies are used to study a tumor's blood flow within intracranial blood vessels. Cerebral angiography may be used to study a tumor's blood supply or obtain information about vascular lesions. An MRI provides information similar to that of a CT scan with improved tissue contrast, resolution and anatomic definition, and it examines the lesion in multiple planes.
Which of the following cranial nerves is responsible for muscles that move the eye and lid? a) Facial b) Oculomotor c) Trigeminal d) Vestibulocochlear
b) Oculomotor Explanation: The oculomotor (III) cranial nerve is also responsible for pupillary constriction and lens accommodation. The trigeminal (V) cranial nerve is responsible for facial sensation, corneal reflex, and mastication. The vestibulocochlear (VII) cranial nerve is responsible for hearing and equilibrium. The facial (VII) nerve is responsible for salivation, tearing, taste, and sensation in the ear.
Which of the following cranial nerves is responsible for facial sensation and corneal reflex? a) Vestibulocochlear b) Trigeminal c) Oculomotor d) Facial
b) Trigeminal Explanation: The trigeminal (V) cranial nerve is also responsible for mastication. The oculomotor (III) cranial nerve is responsible for the muscles that move the eye and lid, pupillary constriction, and lens accommodation. The vestibulocochlear (VII) cranial nerve is responsible for hearing and equilibrium. The facial nerve is responsible for salivation, tearing, taste, and sensation in the ear.
A nurse conducts the Romberg test on a patient by asking the patient to stand with feet close together and eyes closed. As a result of this posture, the patient suddenly sways to one side and is about to fall when the nurse intervenes and saves the patient from being injured. In which of the following ways should the patient's action be interpreted by the nurse? a) Positive Romberg test, indicating a problem with level of consciousness (LOC) b) Negative Romberg test, indicating a problem with body mass c) Positive Romberg test, indicating a problem with equilibrium d) Negative Romberg test, indicating a problem with vision
c) Positive Romberg test, indicating a problem with equilibrium Explanation: If the patient sways and tends to fall during the Romberg test, it indicates a positive Romberg test. This means the patient has a problem with equilibrium. The examiner or the nurse stands fairly close to the patient during the test to prevent the patient from falling. The Romberg test is used to assess the motor function of the patient, including muscle movement, size, tone, strength, and coordination. However, the Romberg test is not used to assess the LOC, body mass, or vision of the patient.
The nurse is assessing the mental status of a patient. Which of the following questions will the nurse include in the assessment? a) "Can you write your name on this piece of paper?" b) "Can you count backward from 100?" c) "Are you having hallucinations now?" d) "Who is the president of the United States?"
d) "Who is the president of the United States?" Explanation: Assessing orientation to time, place, and person assists in evaluating mental status. Does the patient know what day it is, what year it is, and the name of the president of the United States? Is the patient aware of where he or she is? Is the patient aware of who the examiner is and of his or her purpose for being 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 patient's intellectual function. "Are you having hallucinations?" assesses the patient's thought content.
Which of the following terms refers to the inability to coordinate muscle movements, resulting in difficulty walking? a) Agnosia b) Rigidity c) Spasticity d) Ataxia
d) Ataxia Explanation: Ataxia is the inability to coordinate muscle movements, resulting in difficulty walking. 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.
Structural and motor changes related to aging that may be assessed in geriatric patients during an examination of neurologic function include which of the following? a) Enhanced reaction and movement times b) Increased autonomic nervous system responses c) Increased pupillary responses d) Decreased or absent deep tendon reflexes
d) Decreased or absent deep tendon reflexes Explanation: Structural and motor changes related to aging that may be assessed in geriatric patients include decreased or absent deep tendon reflexes. Pupillary responses are reduced or may not appear at all in the presence of cataracts. There is an overall slowing of autonomic nervous system responses. Strength and agility are diminished and reaction and movement times are decreased.
Which of the following terms refer to a method of recording, in graphic form, the electrical activity of the muscle? a) Electrocardiography b) Electrogastrography c) Electroencephalogram d) Electromyogram
d) Electromyogram Explanation: Electromyogram is a method of recording, in graphic form, the electrical activity of the muscle. Electroencephalogram 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.
Which lobe of the brain is responsible for spatial relationships? a) Temporal b) Occipital c) Frontal d) Parietal
d) Parietal Explanation: The parietal lobe is responsible for spatial relationships. The frontal lobe also controls information storage or memory and motor function. The temporal lobe contains the auditory receptive area. The occipital lobe is responsible for visual interpretation.
A patient is scheduled for standard EEG testing to evaluate a possible seizure disorder. Nursing interventions prior to the procedure include which of the following? a) Maintaining NPO status for 6 hours prior to the procedure b) Sedate the patient prior to the procedure, per order c) Instructing the patient that standard EEG takes 2 hours d) Withholding antiseizure medications for 24 to 48 hours prior to the exam
d) Withholding antiseizure medications for 24 to 48 hours prior to the exam Explanation: Antiseizure agents, tranquilizers, stimulants, and depressants should be withheld 24 to 48 hours before an EEG because these medications can alter EEG wave patterns or mask the abnormal wave patterns of seizure disorders. To increase the chances of recording seizure activity, it is sometimes recommended that the patient be deprived of sleep on the night before the EEG. Coffee, tea, chocolate, and cola drinks are omitted in the meal before the test because of their stimulating effect. However, the meal is not omitted, because an altered blood glucose level can cause changes in brain wave patterns. The patient is informed that the standard EEG takes 45 to 60 minutes; a sleep EEG requires 12 hours.
A patient is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in which of the following? a) Intellectual function b) Thought content c) Emotional status d) Motor ability
b) Thought content Explanation: Hallucinations are a disturbance of thought content. They are not disturbances in motor ability, intellectual function, or emotional status.
Which of the following are sympathetic effects of the nervous system? a) Dilated pupils b) Decreased respiratory rate c) Increased peristalsis d) Decreased blood pressure
a) Dilated pupils Explanation: Dilated pupils are a sympathetic effect of the nervous system. Constricted pupils are a parasympathetic effect. Decreased blood pressure is a parasympathetic effect. Increased blood pressure is a sympathetic effect. Increased peristalsis is a parasympathetic effect. Decreased peristalsis is a sympathetic effect. Decreased respiratory rate is a parasympathetic effect. Increased respiratory rate is a sympathetic effect.
The nurse is completing a neurologic assessment and uses the whisper test to assess which of the following cranial nerves? a) Vagus b) Olfactory c) Acoustic d) Facial
c) Acoustic Explanation: Clinical examination of the acoustic nerve can be done by the whisper test. Having the patient say "ah" tests the vagus nerve. Observing for symmetry when the patient performs facial movements tests the facial nerve. The olfactory nerve is tested by having the patient identify specific odors.
If a patient has a lower motor neuron lesion, the nurse would expect which of the following upon physical assessment? a) Muscle spasticity b) Hyperactive reflexes c) Decreased muscle tone d) No muscle atrophy
c) Decreased muscle tone Explanation: A patient with a lower motor neuron lesion would be expected to have decreased muscle tone. Those with upper motor neuron lesion would have hyperactive reflexes, no muscle atrophy, and muscle spasticity.
Which of the following terms refers to the inability to recognize objects through a particular sensory system? a) Aphasia b) Dementia c) Ataxia d) Agnosia
d) Agnosia Explanation: Agnosia may be visual, auditory, or tactile. Dementia refers to organic loss of intellectual function. Ataxia refers to the inability to coordinate muscle movements. Aphasia refers to loss of the ability to express oneself or to understand language.
The nurse is caring for a patient after lumbar puncture. The patient is complaining of a severe headache. Which of the following actions should the nurse complete? Select all that apply. a) Administer fluids to the patient. b) Maintain the patient on bed rest. c) Prepare for an epidural blood patch. d) Administer analgesic medication. e) Position the patient in the supine position.
a) Administer fluids to the patient., b) Maintain the patient on bed rest., d) Administer analgesic medication. Explanation: When the patient assumes an upright position, tension and stretching of the venous sinuses and pain-sensitive structures occur. A postpuncture headache is usually managed by bed rest, analgesic agents, and hydration. Postlumbar puncture headache may be avoided if a small-gauge needle is used and if the patient remains prone after the procedure. When more than 20 mL of the CSF is removed, the patient is positioned supine for 6 hours.
Which of the following safety actions will the nurse implement for a patient receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)? a) Ensure that no patient care equipment containing metal enters the room where the MRI table is located. b) Check the patient's oxygen saturation level using a pulse oximeter after the patient has been placed on the MRI table. c) Securely fasten the patient's portable oxygen tank to the bottom of the MRI table after the patient has been positioned on the top of the MRI table. d) Note that no special safety actions need to be taken.
a) Ensure that no patient care equipment containing metal enters the room where the MRI table is located. Explanation: For patient safety, the nurse must make sure that no patient care equipment (eg, portable oxygen tanks) that contains metal or metal parts enters the room where the MRI is located. The patient must be assessed for the presence of medication patches with foil backing (e.g., nicotine) that may cause a burn. The magnetic field generated by the unit is so strong that any metal-containing items will be strongly attracted and can literally be pulled away with such great force that they can fly like projectiles toward the magnet.
Which of the following supplies cerebrospinal fluid (CSF) to the subarachnoid space and down the spinal cord on the dorsal surface? a) Fourth ventricle b) Arachnoid villus c) Lateral ventricle d) Third ventricle
a) Fourth ventricle Explanation: CSF, which is produced in the ventricles, is circulated around the brain and the spinal cord through the ventricular system. The fourth ventricle supplies CSF to the subarachnoid space and down the spinal cord on the dorsal surface. The third and fourth ventricles connect via the aqueduct of Sylvius. The arachnoid villus is the area in the brain where CSF is absorbed.
A patient is ordered a CT scan of the brain with IV contrast. Prior to the test, the nurse should complete which of the following first? a) Obtain a blood sample for BUN and creatinine levels. b) Maintain the patient NPO for 6 hours prior to the diagnostic test. c) Obtain two large-bore IV lines. d) Assess the patient for medication allergies.
a) Obtain a blood sample for BUN and creatinine levels. Explanation: If a contrast agent is used, the patient must be assessed before the CT scan for an iodine/shellfish allergy, because the contrast agent used may be iodine based. If the patient has no allergies to shell fish, 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 prior to the study. Patients who receive an IV contrast agent are monitored during and after the procedure for allergic reactions and changes in kidney function.
The nurse has completed evaluating the cranial nerves of a patient. The nurse documents impairment of the right cervical nerves (CN IX and CN X). Based on these findings, the nurse will instruct the patient to complete which of the following? a) "While you are in the hospital, wear your hearing aids." b) "Refrain from eating or drinking for now." c) "When you walk, use your walker." d) "Have your husband bring in your glasses."
b) "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 patient to refrain from eating and drinking and contact the health care provider. The other instructions are associated with abnormalities of CN II (optic) and CN VIII (acoustic).
A male patient is scheduled for an EEG. The patient asks about any diet-related prerequisites that he must take. Which of the following diet-related advice should the nurse provide to the patient? a) Avoid eating food at least 8 hours prior to the test. b) Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours prior to the test. c) Include increased amount of minerals in the diet. d) Decrease the amount of minerals in the diet.
b) Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours prior to the test. Explanation: The patient is advised to refrain from taking sedative drugs or drinks that contain caffeine for at least 8 hours prior to the test because these may interfere with the EEG test result. The patient is not advised to increase or decrease the intake of minerals in the diet or to avoid eating food 8 hours before the test.
Which of the following cerebral lobes is the largest and controls abstract thought? a) Temporal b) Frontal c) Occipital d) Parietal
b) Frontal Explanation: 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.
Which of the following is considered an abnormal finding of the Romberg test? a) Tearing of the eye b) Loss of balance c) Hoarseness in the voice d) Deviation of the tongue
b) Loss of balance Explanation: Slight swaying is normal, but a loss of balance is abnormal and is considered a positive Romberg test. Hoarseness in the voice is associated with the vagus nerve. Deviation of the tongue is associated with the hypoglossal. Tearing of the eye is associated with trigeminal nerve.
Which of the following neurotransmitters inhibits pain transmission? a) Dopamine b) Serotonin c) Enkephalin d) Acetylcholine
c) Enkephalin Explanation: Enkephalins are neurotransmitters that inhibit pain transmission. Acetylcholine is an excitatory transmitter. Serotonin is an inhibitory transmitter that helps control mood and sleep. Dopamine usually is inhibitory, affecting behavior and fine movement.
The trochlear nerve serves which of the following functions? a) Visual acuity b) Movement of the tongue c) Eye muscle movement d) Hearing and equilibrium
c) Eye muscle movement Explanation: The trochlear nerve coordinates the muscles that move the eye. The acoustic nerve functions in hearing and equilibrium. The optic nerve functions in visual acuity and visual fields. The hypoglossal nerve functions in the movement of the tongue.
