Chapter 41 - Assessment of the Nervous System
The nurse is about to administer a contrast medium to the client undergoing diagnostic testing. Which question does the nurse first ask the client? "Are you in pain?" "Are you taking ibuprofen daily" "Are you wearing any metal?" "Do you know what this test is for?"
"Are you taking ibuprofen daily" The first question the nurse asks is if the client uses Ibuprofen on a daily basis. Ibuprofen is an NSAID, and daily use may place the client's renal function at risk. The client would also be asked about allergies to contrast agents, daily use of Metformin, and any conditions that may compromise kidney function.Inquiring if a client is in pain is always part of nursing assessment but would not be the first question to ask. The nurse would use this opportunity for education to confirm the client knows the reason for the test and take this time to answer any questions. Diagnostic testing involving magnetic resonance imaging, not contrast medium, requires precautions around metal objects.
A client is scheduled for an electroencephalogram (EEG) in the morning. Which instruction does the nurse give the client? "Do not take any sedatives 12-24 hours before the test." "Please do not have anything to eat or drink after midnight." "You may bring some music to listen to for distraction." "You will need to have someone to drive you home."
"Do not take any sedatives 12-24 hours before the test." Before an EEG, the client needs to be instructed not to use sedatives or stimulants for 12-24 hours prior to the test.A client would not fast prior to an EEG as hypoglycemia may alter results. Testing takes place in a quiet room, so music for distraction is not appropriate. Unless the EEG is for sleep disorder diagnosis, the client will not need to be driven home.
An older client presents to the clinic after a ground level fall at home. What statement by the client indicates the need for more injury prevention education? "I always take my medicine as directed." "I only eat little snacks so I don't gain weight." "I will make sure I drink enough water." "I make sure to get as much sleep as I used to."
"I only eat little snacks so I don't gain weight." More fall injury prevention education is needed when the client says that he/she will only eat little snacks to prevent weight gain. The brain is sensitive to decreased glucose levels which can lead to falls. This is especially noted in older clients.Taking medication as directed, ensuring adequate hydration, nutrition, and sleep help promote nervous system health and decrease the risk for falls in the elderly.
Which client will the neurologic unit charge nurse assign to a registered nurse who has floated from the labor/delivery unit for the shift? Adult client who has just returned from having a cerebral arteriogram and needs vital sign checks every 15 minutes. Older adult client who was just admitted with a stroke and needs an admission assessment. Young adult client who has had a lumbar puncture and reports, "Light hurts my eyes." Middle-aged client who has a possible brain tumor and has questions about the scheduled magnetic resonance imaging.
Adult client who has just returned from having a cerebral arteriogram and needs vital sign checks every 15 minutes. The charge nurse would assign an RN with experience in labor and delivery to check vital signs and limbs on a client who just returned from a cerebral angiogram. This float nurse would also be able to recognize signs of bleeding.The older adult admitted with a stroke, the young adult post lumbar puncture, and the middle-aged client with a possible brain tumor all require a nurse with more experience with neurologic diagnoses and diagnostic procedures.
Which task does the nurse plan to delegate to the unlicensed assistive personnel (UAP) caring for a group of clients in the neurosurgical unit? Assist the health care provider in performing a lumbar puncture on a confused client Attend to the care needs of a client who has had a transcranial Doppler study Educate a client about what to expect during an electroencephalogram (EEG) Prepare a client who is going to radiology for a cerebral arteriogram
Attend to the care needs of a client who has had a transcranial Doppler study The nurse delegates the UAP to care for the client who has had a transcranial Doppler study. Since transcranial Doppler studies are noninvasive and do not require any postprocedure monitoring or care the UAP can safely attend to this client.Assisting the primary care provider in performing a lumbar puncture and preparing a client for a cerebral arteriogram require assessments and interventions that would be done by licensed nursing staff. Client teaching would also be provided by licensed nursing staff.
A client has just returned from cerebral angiography. Which symptom does the client display that causes the nurse to act immediately? Bleeding Increased temperature Severe headache Urge to void
Bleeding After a cerebral angiography, the nurse would immediately react if the client had any bleeding. If bleeding is present at the puncture site, manual pressure on the site is maintained along with immediate notification of the primary care provider.Increased temperature or the urge to void are not typical complications of cerebral angiography. Severe headache is a typical complication of a lumbar puncture, but not of cerebral angiography.
The nurse is caring for a client who is scheduled to have a transcranial Doppler (TCD). What does this diagnostic test evaluate? Cerebral vasospasm Cerebrospinal fluid Evoked potentials Intracranial pressure
Cerebral vasospasm A transcranial Doppler (TCD) is used to evaluate cerebral vasospasm or narrowing of arteries. It is noninvasive.Cerebrospinal fluid is obtained and measured during a lumbar puncture (LP). Evoked potentials measure the electrical signals in the brain during an EEG. Intracranial pressure is a measurement of blood, brain tissue, and cerebral spinal fluid and is not measured by TCD.
The nurse has just received report on a group of clients. Which client does the nurse assess first? Client who was in a car accident and has a Glasgow Coma Scale score of 14 Client who had a cerebral arteriogram and has a cool, pale leg Client who has a headache after undergoing a lumbar puncture Client who has expressive aphasia after a left-sided stroke
Client who had a cerebral arteriogram and has a cool, pale leg The nurse first assesses the client with a cool, pale leg after an arteriogram. This assessment finding could indicate clot formation at the catheter insertion site and loss of blood flow to the extremity.The client with a GCS of 14, the client with a headache following a lumbar puncture, and the client with expressive aphasia need to be assessed as soon as possible.
The nurse has just received report on a group of clients on the neurosurgical unit. Which client is the nurse's first priority? Client whose deep tendon reflexes have become hyperactive Client who displays plantar flexion when the bottom of the foot is stroked Client who consistently demonstrates decortication when stimulated Client whose Glasgow Coma Scale (GCS) has changed from 15 to 13.
Client whose Glasgow Coma Scale (GCS) has changed from 15 to 13. After receiving report on a group of clients, the nurse's first priority is to assess the client whose GCS has changed from 15 to 13. A decrease of 2 or more points in the Glasgow Coma Scale total is clinically significant and indicates a major change in neurologic status. This finding must be reported immediately to the primary health care provider (PHCP).The client with hyperactive reflexes, the client displaying plantar flexion when the bottom of the foot is stroked, and the client with decortication upon stimulation will need to be assessed, but they do not require immediate attention.
The nurse prepares to assess a client with diabetes mellitus for sensory loss. Which equipment is the best choice for the nurse use to perform this assessment? Cotton-tipped applicator Glucometer Hammer Safety pin
Cotton-tipped applicator A cotton-tipped applicator is the nurse's best choice to assess sensory loss on a client with diabetes mellitus. Sensory loss is assessed with any sharp or dull object, such as a cotton-tipped applicator. The client indicates whether the touch is sharp or dull. The soft and hard ends of the applicator would be interchanged at random so that the client does not anticipate the next type of sensation. A glucometer tests blood sugar. A hammer tests tendon reflexes. Although a safety pin could be used to test for sensory loss, a cotton-tipped applicator is safer in the event the client is taking anticoagulants.
The nurse is performing a neurologic assessment on an 81-year-old client. Which physiologic change does the nurse expect to find because of the client's age? Decreased coordination Increased sleeping during the night Increased touch sensation Nightly confusion
Decreased coordination When performing a neurologic assessment on an elderly client, the nurse expects to find decreased coordination. Older adults experience decreased coordination as a result of the aging process.Older adults frequently go to bed earlier and arise earlier than younger adults. Sensation to touch is decreased not increased. Nightly confusion, sometimes referred to as "sundowning," is not an expected change with all older adults.
The nurse is performing a rapid neurologic assessment on a trauma client. Which assessment findings are normal? Select all that apply. Decerebrate posturing Glasgow Coma Score (GCS) 15 Lethargy Minimal response to stimulation Pupil constriction to light
Glasgow Coma Score (GCS) 15 Minimal response to stimulation Normal rapid neurologic assessment findings include a GCS (Glasgow Coma Score) of 15 and pupil constriction to light. The GCS range is between 3 and 15. Pupil constriction is a function of cranial nerve III. The pupils would be equal in size and round and regular in shape and would react to light and accommodation (PERRLA).Decerebrate or decorticate posturing is not normal, as well as pinpoint or dilated and nonreactive pupils. Both of findings are a late sign of neurologic deterioration. In addition, minimal response to stimulation and increased lethargy are not normal findings.
The nurse has just received change-of-shift report about a group of clients on the neurosurgical unit. Which client does the nurse attend to first? Adult postoperative left craniotomy client whose hand grip is weaker on the right Middle-aged adult client who had a cerebral aneurysm clipping and is becoming increasingly confused Older adult client who had a carotid endarterectomy and is unable to state the day of the week Young adult client involved in a motor vehicle crash (MVC) who is yelling obscenities at the nursing staff
Middle-aged adult client who had a cerebral aneurysm clipping and is becoming increasingly confused After a change-of-shift report, the neurosurgical nurse would first attend to the middle-aged client who had a clipping of a cerebral aneurysm and is now becoming increasingly confused. A change in level of consciousness is an early indication that central neurologic function has declined. The primary care provider must be notified immediately.The other clients are not the nurse's first priority. The young adult who is post-MVC does need to be assessed, but the client's behavior does not indicate a decline in neurologic function. The postoperative left craniotomy client and the older adult also need to be assessed, but these clients' neurologic assessment indicates better function.
Which information is most important for the nurse to communicate to the primary care provider (PCP) about a client who is scheduled for CT angiography? Allergy to penicillin History of bacterial meningitis Poor skin turgor and dry mucous membranes The client's dose of metformin (Glucophage) held today
Poor skin turgor and dry mucous membranes The most important information for the nurse to communicate to the PCP about a client scheduled for a CT angiography is the client with poor skin turgor and dry mucous membranes. This assessment indicates dehydration which places the client at risk for contrast induced nephropathy.Allergy to penicillin, history of bacterial meningitis, and withheld metformin will need to be reported as part of the client hand-off to Radiology (SAFETY).
The nurse is assessing a client with a neurologic condition who is reporting difficulty chewing when eating. The nurse suspects that which cranial nerve has been affected? Abducens (CN VI) Facial (CN VII) Trigeminal (CN V) Trochlear (CN IV)
Trigeminal (CN V) The nurse suspects that the trigeminal cranial nerve is affected when a client complains of difficulty chewing when eating. The trigeminal nerve affects the muscles of mastication.The abducens nerve affects eye movement via lateral rectus muscles. The facial nerve affects pain and temperature from the ear area, deep sensations in the face, and taste in the anterior two-thirds of the tongue. The trochlear nerve affects eye movement via superior oblique muscles.
Which cranial nerve allows a person to feel a light breeze on the face? I (olfactory) III (oculomotor) V (trigeminal) VII (facial)
V (trigeminal) Cranial nerve V (trigeminal) allows the person to feel a light breeze on the face. This nerve is responsible for sensation from the skin of the face and scalp and the mucous membranes of the mouth and nose.Cranial nerve I (olfactory) is responsible for smell. Cranial nerve III (oculomotor) is responsible for eye movement. Cranial nerve VII (facial) is responsible for pain and temperature from the ear area, deep sensations from the face, and taste from the anterior two thirds of the tongue.
Which client diagnosed with neurologic injury is typically at highest risk for depression? Older man with a mild stroke Older woman with a seizure Young man with a spinal cord injury Young woman with a minor closed head injury
Young man with a spinal cord injury A young man with a spinal cord injury is at highest risk for depression. Although each individual responds differently, young adults who experience a spinal cord injury and loss of independent movement are more likely to experience depression.Keeping in mind people's differences in personal experiences, the client with a mild stroke without long-term deficits, the client who had a seizure or the young woman who sustained a minor head injury are generally at a lower risk of depression.
