Chap 65-Assessment of Neurologic Function

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? a) Frontal b) Temporal c) Parietal d) Occipital

d) Occipital

Which of the following neurotransmitters are deficient in myasthenia gravis? a) Dopamine b) Acetylcholine c) Serotonin d) GABA

b) Acetylcholine

Lesions in the temporal lobe may result in which type of agnosia? a) Relationship b) Auditory c) Visual d) Tactile

b) Auditory

Which of the following cerebral lobes is the largest and controls abstract thought? a) Temporal b) Frontal c) Parietal d) Occipital

b) Frontal

To evaluate a client's cerebellar function, a nurse should ask: a) "Have you noticed any changes in your muscle strength?" b) "Do you have any trouble swallowing food or fluids?" c) "Do you have any problems with balance?" d) "Do you have any difficulty speaking?"

c) "Do you have any problems with balance?"

A patient who has suffered a stroke is unable to maintain respiration and so is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe? a) Frontal lobe b) Parietal lobe c) Brain stem d) Occipital lobe

c) Brain stem

The pre-nursing class is learning about the nervous system in their anatomy class. What part of the nervous system would the students learn is responsible for digesting food and eliminating body waste? a) Sympathetic b) Peripheral c) Parasympathetic d) Central

c) Parasympathetic

The nurse is performing a neurologic assessment on a client diagnosed with a stroke and cannot elicit a gag reflex. This deficit is related to which of the following cranial nerves? a) III b) VII c) X d) VIII

c) X

Which term refers to a method of recording, in graphic form, the electrical activity of a muscle? a) Electrocardiography b) Electrogastrography c) Electroencephalography d) Electromyography

d) Electromyography

The nurse is performing a neurological assessment of a client who has sustained damage to the frontal cortex. Which of the following deficits will the nurse look for during assessment? a) Intentional tremors b) Absence of movement below the waist c) The inability to maintain steady balance for the Romberg test d) The inability to tell how a mouse and a cat are alike

d) The inability to tell how a mouse and a cat are alike

The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve? a) CN I b) CN III c) CN II d) CN IV

a) CN I

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: a) Cerebellum. b) Pons. c) Midbrain. d) Medulla oblongata.

a) Cerebellum

The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm? a) Cerebral angiography b) Myelogram c) Electroencephalogram d) Echoencephalography

a) Cerebral angiography

The critical care nurse is giving report on a client they are caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the on-coming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? a) Comatose b) Somnolence c) Normal d) Stupor

a) Comatose

A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test? a) Determine whether the client is allergic to iodine, contrast dyes, or shellfish. b) Administer a sedative as ordered. c) Place a cap over the client's head. d) Immobilize the neck before the client is moved onto a stretcher.

a) Determine whether the client is allergic to iodine, contrast dyes, or shellfish.

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.

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? a) Flaccidity b) Decorticate posturing c) Abnormal posture d) Weak muscular tone

a) Flaccidity

A nurse is preparing a client for lumbar puncture. The client has heard about post-lumbar puncture headaches and asks how to avoid having one. The nurse tells the client that these headches can be avoided by doing which of the following after the procedure? a) "Remain NPO for 6 hours." b) "Remain prone for 2 to 3 hours." c) "Remain on bedrest for 3 days." d) "Ambulate as soon as possible."

b) "Remain prone for 2 to 3 hours."

A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first? a) Obtain a blood sample to evaluate BUN and creatinine concentrations. b) Assess the client for medication allergies. c) Obtain two large-bore IV lines. d) Maintain the client NPO for 6 hours before the test.

b) Assess the client for medication allergies.

A nurse is preparing a client for a lumbar puncture. The client has heard about post-lumbar puncture headaches and asks what causes them. The nurse tells the client that these headaches are caused by which of the following? a) Traumatic puncture b) Cerebral spinal fluid leakage at the puncture site c) Damage to the spinal cord d) Not ambulating soon enough after the procedure

b) Cerebral spinal fluid leakage at the puncture site

The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of cranial nerve: a) XI b) VIII c) II d) VI

b) VIII

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: a) cranial nerves VI and VIII. b) cranial nerves IX and X. c) cranial nerves I and II. d) cranial nerves III and V.

b) cranial nerves IX and X.

Lower motor neuron lesions cause a) increased muscle tone. b) flaccid muscles. c) hyperactive and abnormal reflexes. d) no muscle atrophy.

b) flaccid muscles.

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? a) "It is a test for coordination." b) "It is a test for muscle strength." c) "It is a test for balance." d) "It is a test for motor ability."

c) "It is a test for balance."

Which term refers to the inability to coordinate muscle movements, resulting in difficulty walking? a) Agnosia b) Spasticity c) Ataxia d) Rigidity

c) Ataxia

A client is scheduled for an EEG. The client inquires about any diet-related prerequisites before the EEG. Which diet-related advice should the nurse provide to the client? a) Include an increased amount of minerals in the diet b) Decrease the amount of minerals in the diet c) Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours before the test d) Avoid eating food for at least 8 hours before the test

c) Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours before the test

A patient is scheduled for an electroencephalogram (EEG) in the morning. What food on the patient's tray should the nurse remove prior to the test? a) Toast b) Eggs c) Coffee d) Orange juice

c) Coffee

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? a) Help the client take a brisk walk around the testing area b) Administer antihistamines according to the physician's prescription c) Encourage the client to drink liberal amounts of fluids d) Keep the room brightly lit and play soothing music in the background

c) Encourage the client to drink liberal amounts of fluids

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? a) Parietal lobe b) Occipital lobe c) Frontal lobe d) Temporal lobe

c) Frontal lobe

Which of the following areas of the brain are responsible for temperature regulation? a) Medulla b) Thalamus c) Hypothalamus d) Pons

c) Hypothalamus

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure? a) Supine, with the knees raised toward the chest b) Prone, with the head turned to the right c) Lateral recumbent, with chin resting on flexed knees d) Lateral, with right leg flexed

c) Lateral recumbent, with chin resting on flexed knees

A nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm? a) milligram b) electroencephalogram c) cerebral angiography d) echoencephalography

c) cerebral angiography

If a client has a lower motor neuron lesion, the nurse would expect the client to exhibit a) hyperactive reflexes. b) muscle spasticity. c) decreased muscle tone. d) no muscle atrophy.

c) decreased muscle tone.

The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse should respond by describing the action of the: a) parasympathetic nervous system. b) endocrine system. c) sympathetic nervous system. d) musculoskeletal system.

c) sympathetic nervous system

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? a) "The blood can repair damage to the spinal cord that occurred with the procedure." b) "The blood will replace the cerebral spinal fluid that has leaked out." c) "The blood provides moisture at the site, which encourages healing." d) "The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid."

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

Which diagnostic test may be performed to evaluate blood flow within intracranial blood vessels? a) Cerebral angiography b) Computed tomography c) Magnetic resonance imaging d) Transcranial Doppler

d) Transcranial Doppler

The spinal cord is composed of 31 pairs of spinal nerves. How many pairs of thoracic nerves are contained within the spinal column? a) Eight b) Five c) One d) Twelve

d) Twelve

The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern? a) Cerebrospinal fluid is cloudy in nature. b) Physician maintains aseptic procedure. c) Client states a pressure relief in the head. d) Client states a piercing feeling.

a) Cerebrospinal fluid is cloudy in nature.

A male client is scheduled for an electroencephalogram (EEG). When the nurse caring for the client is preparing him for the test, the client states that during childhood he was mildly electrocuted but miraculously lived. Therefore, he is quite afraid of going through an EEG. In what ways can the nurse help dispel the client's fear regarding the test? a) Inform the client that he will not experience any electrical shock. b) Distract the client's attention from the test. c) Inform the client that he will experience only mild electrical shock. d) Encourage adequate water intake by the client.

a) Inform the client that he will not experience any electrical shock.

A nurse is completing a neurological assessment and determines that the client has significant visual deficits. A brain tumor is considered. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit? a) Occipital b) Frontal c) Pariétal d) Temporal

a) Occipital

Which neurotransmitter demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways? a) Serotonin b) Enkephalin c) Norepinephrine d) Acetylcholine

a) Serotonin

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? a) occipital b) parietal c) frontal d) temporal

a) occipital

The nurse is caring for a client newly diagnosed with multiple sclerosis who is overwhelmed by learning about the disease. The client indicates understanding that there is a disruption in the covering of axons but does not remember what the covering is called. The nurse should tell the client: a) that the covering is called myelin and that it can be discussed further at the next meeting. b) that the disease process requires more research. c) not to worry about the fine details. d) that because there is so much to learn, there will be another meeting to discuss it again.

a) that the covering is called myelin and that it can be discussed further at the next meeting.

A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in a) thought content. b) intellectual function. c) emotional status. d) motor ability.

a) thought content.

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 a) wear any hearing aids while in the hospital. b) refrain from eating or drinking for now. c) use the walker when walking. d) have their spouse bring in the client's glasses.

b) refrain from eating or drinking for now.

A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult slowing transmission of the motor neurons, the nurse would anticipate a delayed reaction in: a) identification of information due to slowed passages of information to brain. b) response due to interrupted impulses from the central nervous system c) processing information transferred from the environment. d) cognitive ability to understand relayed information.

b) response due to interrupted impulses from the central nervous system

A client is scheduled for standard EEG testing to evaluate a possible seizure disorder. Which nursing intervention should the nurse perform before the procedure? a) Sedate the client before the procedure, per orders b) Instruct the client that a standard EEG takes 2 hours c) Maintain NPO status for 6 hours before the procedure d) Withhold anticonvulsant medications for 24 to 48 hours before the exam

d) Withhold anticonvulsant medications for 24 to 48 hours before the exam

A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects in the body systems, the nurse anticipates that the liver will: a) cease function and shunt blood to the heart and lungs. b) maintain a basal rate of functioning. c) produce a toxic byproduct in relation to stress. d) convert glycogen to glucose for immediate use.

d) convert glycogen to glucose for immediate use.