Chapter 43 PrepU

A patient with a neurological disorder is being assessed by the nurse. The nurse assesses the patient's biceps reflex as diminished. The nurse would be correct in documenting this response as what?

1+

SATA Age-related changes in the neurologic system must be carefully assessed. Which of the following changes does the nurse expect to find in some degree depending on the patient's age and medical condition?

Decreased muscle mass Increased sensitivity to heat and cold Reduced papillary responses

A patient has a deficiency of the neurotransmitter serotonin. The nurse is aware that this deficiency can lead to:

Depression

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?

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

SATA A patient had a lumbar puncture 3 days ago in the outpatient clinic and calls the nurse with complaints of a throbbing headache. What can the nurse educate the patient to do for relief of the discomfort?

Force fluids (unless contraindicated). Get plenty of bed rest. Take some over-the-counter analgesics.

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?

Helicopod

Which lobe of the brain is responsible for spatial relationships?

Parietal

A patient is treated for a neurologic dysfunction affecting facial expressions. The affected cranial nerve originates in the:

Pons

A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture?

Position the client flat for at least 3 hours.

A nurse is performing a neurologic assessment on a client. The nurse observes the client's tongue for symmetry, tremors, and strength, and assesses the client's speech. Which cranial nerve is the nurse assessing?

XIII

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?

cerebral angiography

If a client has a lower motor neuron lesion, the nurse would expect the client to exhibit

decreased muscle tone.

During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to:

support the joint where the tendon is being tested.

To evaluate a client's cerebellar function, a nurse should ask:

"Do you have any problems with balance?"

A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following?

"There is a strong familial tendency."

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.

Which is a sympathetic effect of the nervous system?

Dilated pupils

Which lobe of the brain is responsible for concentration and abstract thought?

Frontal

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?

X

Lower motor neuron lesions cause

flaccid muscles.

Which neurotransmitter inhibits pain transmission?

Enkephalin

Which term describes the fibrous connective tissues that cover the brain and spinal cord?

Meninges

A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain?

V

The nurse is performing a detailed mental status assessment of an older adult patient who has a diagnosis of mild Alzheimer's disease. What assessment most accurately gauges the patient's abstract reasoning?

"What would you do if you found a stamped envelope on the street?"

Which of the following neurotransmitters are deficient in myasthenia gravis?

Acetylcholine

A client has sustained a head injury to the parietal lobe and cannot identify a familiar object by touch. The nurse knows that this deficit is

Astereognosis

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?

CN I

There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected with decreased visual fields.

Cranial nerve II

The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve?

Cranial nerve XII

If a client has a lower motor neuron lesion, the nurse would expect to observe which manifestation upon physical assessment?

Decreased muscle tone

A 53-year-old man presents to the emergency department with a chief complaint of inability to form words, and numbness and weakness of the right arm and leg. Where would you locate the site of injury?

Left frontoparietal region

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

During a neurological assessment examination, the nurse assesses a patient for tactile agnosia. The nurse places a familiar door key in the patient's hand and asks him to identify the object with his eyes closed. The nurse documents his inability to identify the object and notes the affected area of the brain. Which of the following is the most likely affected area of the brain?

Parietal lobe

SATA The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern?

Unequal pupils Pinpoint pupils Absence of pupillary response

A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements?

"A secondary headache is associated with an organic cause, such as a brain tumor."

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 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?

Coffee

SATA The nurse is completing the physical assessment of a patient suspected of a neurologic disorder. The patient reports to the nurse that he has recently suffered a head trauma. In such a case, which of the following precautions should the nurse take for the patient?

The nurse should not move or manipulate the patient's head while assessing for bleeding or swelling

The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart?

CN II

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?

Flaccidity

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

Hypothalamus

A 77-year-old female patient who is recovering in the hospital from a total knee replacement has rung her call bell and told the nurse that she needs pain medication. When assessing the patient's pain, what principle should the nurse bear in mind?

Older adults tend to have a blunted pain sensation, so complaints should be followed-up promptly.

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

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:

response due to interrupted impulses from the central nervous system

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."

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates:

dysfunction in the brain stem.

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?

Lateral recumbent, with chin resting on flexed knees

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:

VIII

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?

heartbeat to decrease

A critical care nurse is documenting the assessment of a client. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. This means that the client:

is not responding to stimuli.

A 30-year-old primiparous woman has been admitted in early labor. The obstetrical nurse has read on the patient's prenatal record that she has a history of seizures. The nurse should understand that seizures most often occur as a result of:

Abnormal activity in the cerebral cortex

What is the function of cerebrospinal fluid (CSF)?

It cushions the brain and spinal cord.

The admission assessment form on a neurological unit requires the admitting nurse to assess each patient's superficial reflexes. To assess a patient's corneal reflex, the nurse should:

Lightly touch the patient's sclera with some wisps of cotton.

The nurse 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

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

A patient has been diagnosed with damage to Broca's area of the left frontal lobe. To document the extent of damage, the nurse would assess the patient's:

Speech

A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with:

body temperature control.

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:

convert glycogen to glucose for immediate use.

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

A middle-aged woman has scheduled an appointment with her nurse practitioner because she has been experiencing intractable muscle weakness in recent weeks. Which of the following characteristics of the patient's weakness should cause the nurse to suspect a neurological etiology?

The weakness is primarily on the left side of the patient's body.

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.