Chapter 60: Assessment of Neuro Fucntion

A client preparing to undergo a lumbar puncture states he doesn't think he will be able to get comfortable with his knees drawn up to his abdomen and his chin touching his chest. He asks if he can lie on his left side. Which statement is the best response by the nurse?

"Although the required position may not be comfortable, it will make the procedure safer and easier to perform."

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

"Do you have any problems with balance?"

To help assess a client's cerebral function, a nurse should ask:

"Have you noticed a change in your memory?"

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."

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."

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."

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?"

The cerebral circulation receives approximately what percentage of the cardiac output?

15%

Which of the following neurotransmitters are deficient in myasthenia gravis?

Acetylcholine

The nurse is completing a neurologic assessment and uses the whisper test to assess which cranial nerve?

Acoustic

A client undergoes a scheduled electroencephalogram (EEG). Which of the following post-procedure activities should the nurse carry out for the client?

Allow the client to rest and shampoo the client's hair.

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 term refers to the inability to coordinate muscle movements, resulting difficulty walking?

Ataxia

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

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

What part of the brain controls and coordinates muscle movement?

Cerebellum

Which of the following terms is used to describe rapid, jerky, involuntary, purposeless movements of the extremities?

Chorea

A nurse is working in a neurologist's office. The physician orders a Romberg test. What should the nurse instruct the client to do?

Close eyes and stand erect.

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, what does the nurse anticipate the liver will do?

Convert glycogen to glucose for immediate use.

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

Decreased muscle tone

Which of the following is a sympathetic nervous system effect?

Decreased peristalsis

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

Depression

Low levels of the neurotransmitter serotonin lead to which of the following disease processes?

Depression

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 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?

Encourage the client to drink liberal amounts of fluids

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? Select all that apply.

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

Which cerebral lobes is the largest and controls abstract thought?

Frontal

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

Frontal

Cranial nerve IX is also known as which of the following?

Glossopharyngeal

A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position?

Head of the bed elevated 45 degrees

A comatose client is being cared for by a critical care nurse who documents that the client responds only to very painful stimuli by fragmentary, delayed reflex withdrawal. The nurse knows that reflexes in the body are centered where?

In the spinal cord

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

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

Which cranial nerve is responsible for muscles that move the eye and lids?

Oculomotor

A patient has difficulty interpreting his awareness of body position in space. Which lobe is most likely to be damaged?

Parietal

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 that is slowing transmission of the motor neurons, in what would the nurse anticipate a delayed reaction?

Response due to interrupted impulses from the central nervous system

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 who has sustained a head injury to the parietal lobe cannot identify a familiar object by touch. The nurse knows that this deficit is which of the following?

Tactile agnosia

The nurse assists the health care provider (HCP) in completing a lumbar puncture (LP). Which should the nurse note as a concern?

The cerebrospinal fluid (CSF) is cloudy in nature.

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 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 which cranial nerve?

VIII

The provider orders the Romberg test for a patient. The nurse tells the patient that the provider wants to evaluate his equilibrium by assessing which cranial nerve?

VIII

A client is scheduled for standard EEG testing to evaluate a possible seizure disorder. Which nursing intervention should the nurse perform before the procedure?

Withhold anticonvulsant medications for 24 to 48 hours before the exam

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

body temperature control.

A patient who has suffered a stroke is unable to maintain respiration and is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe?

brain stem

Lower motor neuron lesions cause

flaccid muscles.

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

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

pons

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.

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:

sympathetic nervous system.

A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in

thought content.