Chapter 60 prepu

Hypoxia.

A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for:

Occipital

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?

Risk for falls

In reviewing a client's history and physical examination, a nurse finds that the client was found positive for ataxia during the physician's neurological testing. Which nursing diagnosis will be a priority for this client?

second lumbar vertebrae

The nurse is caring for a client who is to have a lumbar puncture. What are the lowest vertebrae that contain the spinal cord?

1+

The nurse is caring for a patient who was involved in a motor vehicle accident and sustained a head injury. When assessing deep tendon reflexes (DTR), the nurse observes diminished or hypoactive reflexes. How will the nurse document this finding?

Acoustic

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

VIII

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?

Serves as a conduit for impulses to and from the brain

The nursing instructor is talking with her clinical group about the central nervous system. What should the instructor tell the students about the function of the spinal cord?

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?

Acetylcholine

Which of the following neurotransmitters are deficient in myasthenia gravis?

Helicopod

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?

a disturbance in thought content

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

Occipital

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?

Assess the client for medication allergies.

A client is ordered to undergo CT of the brain with IV contrast. Before the test,the nurse should complete which action first?

Withhold anticonvulsant medications for 24 to 48 hours before the exam

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

Convert glycogen to glucose for immediate use.

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 hand wringing. Considering the effects in the body systems, what does the nurse anticipate the liver will do?

Position the client flat as directed.

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?

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

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?

Tactile Agnosia

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?

turning the client's head suddenly while holding the eyelids open.

A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic(doll's eye) response by:

Provide brief instructions, one step at at time

A geriatric nurse practitioner is assessing older adults. The nurse practitioner knows that older adults sometimes have difficulty following directions during a neurologic examination or diagnostic procedure. What strategies can the nurse practitioner use to examine older clients?

VI (Abducens)

A high school soccer player sustained five concussions before she was told that she should never play contact sports again. After her last injury, she began experiencing episodes of double vision. She was told that she had most likely incurred damage to which cranial nerve?

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

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?

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

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?

Lateral recumbent, with thighs flexed

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

Head of the bed elevated 45 degrees

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?

medulla oblongata

A nurse is noting from a client's neurologic assessment findings that the client's motor impulses are interrupted from the brain to the spinal cord. It also appears that the client lacks sensory impulses from the peripheral sensory neurons to the brain. Which area has the deficit?

Risk for aspiration

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis?

XII

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?

VIII

A nurse is performing a neurologic assessment on the client and notes a positive Romberg test. This test for balance is related to which of the following cranial nerves?

Cerebral spinal fluid leakage at the puncture site

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?

Close eyes and stand erect

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

Shampoo

A nurse is working in an outpatient studies unit administering neurological tests. The client is surprised that paste is used to secure an electroencephalogram and asks how it will be removed from the hair. With what substance does the nurse reply?

dysfunction in the brain stem

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

"I am trying to quit smoking and have a patch on."

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?

V

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?

Depression

A patient has been diagnosed with a deficiency of the major neurotransmitter acetylcholine. Based on this information, the nurse knows to assess the patient for complications associated with:

Heart rate and rhythm

A patient has been diagnosed with a deficiency of the major neurotransmitter acetylcholine. Based on this information, the nurse knows to assess the patient for complications associated with:

Speech

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:

parietal

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

Dysfunction of the vagus nerve

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?

Have the patient lie flat for 6 hours.

A patient is having a lumbar puncture and the physician has removed 20 mL of cerebrospinal fluid. What nursing intervention is a priority after the procedure?

Cerebellum

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:

Frontal lobe

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?

Brain stem

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?

evaluation of the corneal reflex response.

After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an:

Allergic reaction to the imaging material

The nurse is caring for a client who is undergoing single-photon emission computed tomography (SPECT). What is a potential side effect that this client may suffer?

observing the client's response to painful stimulus

The nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response?

X

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?

CN I

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?

Moving the head and chin toward the chest

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?

CN II

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

Cerebral angiography

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?

Parasympathetic

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?

Twelve

The spinal cord is composed of 31 pairs of spinal nerves. How many pairs of thoracic nerves are contained within the spinal column?

Heartbeat to decrease

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?

Eye muscle movement

The trochlear nerve controls which function?

Cranial nerve II

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

gag reflex.

To assess a client's cranial nerve function, a nurse should assess:

"Do you have any problems with balance?"

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

It cushions the brain and spinal cord.

What is the function of cerebrospinal fluid (CSF)?

Cerebellum

What part of the brain controls and coordinates muscle movement?

Sympathetic

When learning about the nervous system, students learn that which nervous system regulates the expenditure of energy?

Temporalis

Which cerebral lobe contains the auditory receptive areas?

Frontal

Which cerebral lobes is the largest and controls abstract thought?

Trigeminal

Which cranial nerve is responsible for facial sensation and corneal reflex?

Oculomotor

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

Acoustic

Which cranial nerve is tested by listening to a ticking watch?

Transcranial Doppler

Which diagnostic test may be performed to evaluate blood flow within intracranial blood vessels?

Dilated pupils

Which is a sympathetic effect of the nervous system?

Frontal

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

Parietal

Which lobe of the brain is responsible for spatial relationships?

Serotonin

Which neurotransmitter demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways?

Enkephalin

Which neurotransmitter inhibits pain transmission?

Decreased peristalsis

Which of the following is a sympathetic nervous system effect?

Loss of neurons in the brain

Which of the following is an age-related change in the nervous system?

Meninges

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

Electromyography

Which term refers to a method of recording, in graphic form, the electrical activity of a muscle?

Ataxia

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

Left frontoparietal region

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?

Visual agnosia

A client has sustained a head injury to the occipital area. He cannot identify a familiar object by looking at it. The nurse knows that this deficit is which of the following?

Astereognosis

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

Encourage the client to drink liberal amounts of fluids

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 post procedure nursing intervention should be performed to ensure the client's maximum comfort?

Response due to interrupted impulses from the central nervous system

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?

Auditory

Lesions in the temporal lobe may result in which type of agnosia?

Glossopharyngeal

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

Parietal lobe

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?

support the joint where the tendon is being tested.

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

Decreased muscle tone

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

Agnosia definition

Which term refers to the inability to recognize objects through a particular sensory system?

Comatose

The critical care nurse is giving end-of-shift report on a client. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate?

refrain from eating or drinking for now.

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 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?

"Who is the president of the United States?"

The nurse is assessing the client's mental status . Which question will the nurse include in the assessment?

Constricted pupils

The nurse is assessing the pupils of a patient who has had a head injury. What does the nurse recognize as a parasympathetic effect?

Cranial nerve XII

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?

Moving the client's head to clean behind the ears

The nurse is caring for a client in the emergency department with a diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the client's face and torso. Which action by the nurse aide would prompt the nurse to provide further instruction?