chapter65 - PrepU - Nursing Assessment: Neurologic Function

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? 1- "A secondary headache is one for which no organic cause can be identified." 2- "A secondary headache is located in the frontal area." 3- "A secondary headache is associated with an organic cause, such as a brain tumor." 4- "A migraine headache is an example of a secondary headache."

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

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? 1- "Lying on your left side will be fine during the procedure." 2- "There's no other option but to assume the knee-chest position." 3- "Although the required position may not be comfortable, it will make the procedure safer and easier to perform." 4- "I'll report your concerns to the physician."

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

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? 1- "I am trying to quit smoking and have a patch on." 2- "I have been trying to get an appointment for so long." 3- "I have not had anything to eat or drink since 3 hours ago." 4- "My legs go numb sometimes when I sit too long."

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

A patient who has been diagnosed with colon cancer is scheduled to undergo positron emission tomography (PET) to search for metastases. In preparation for this diagnostic procedure, what teaching point should the nurse provide to the patient? 1- "Sound waves will be refracted throughout your body and a computer will analyze them." 2- "A series of X-rays will be taken that will be combined to create a three-dimensional image your body." 3- "It's very important that all metal objects be removed from your body before the test." 4- "You'll be given a radioactive substance that will be measured during the test."

"You'll be given a radioactive substance that will be measured during the test."

To help assess a client's cerebral function, a nurse should ask: -"Have you noticed a change in your memory?" -"Have you noticed a change in your muscle strength?" -"Have you had any problems with coordination?" -"Have you had any problems with your eyes?"

-"Have you noticed a change in your memory?" To assess cerebral function, the nurse should ask about the client's level of consciousness, orientation, memory, and other aspects of mental status. Questions about muscle strength help evaluate the client's motor system. Questions about coordination help her assess cerebellar function. Questions about eyesight help the nurse evaluate the cranial nerves associated with vision.

The anatomy instructor is discussing the central nervous system. A student asks where the cerebral cortex is located. What should the anatomy instructor answer? -"It is located on the surface of the cerebrum." -"It is located in the center of the cerebellum." -"It is located at the base of the brain." -"It is located between the left and right hemispheres of the brain."

-"It is located on the surface of the cerebrum."

Which of the following is a disorder due to a lesion in the basal ganglia? -Parkinson's disease -Guillain-Barré -Myasthenia gravis -Multiple sclerosis

-Parkinson's disease Disorders due to lesions of the basal ganglia include Parkinson's disease, Huntington's disease, and spasmodic torticollis.

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? -midbrain -medulla oblongata -pons -subarachnoid space

-medulla oblongata The medulla oblongata lies below the pons and transmits motor impulses from the brain to the spinal cord, and sensory impulses from the peripheral sensory neurons to the brain. The pons is part of the brainstem. The midbrain forms the forward part of the brainstem and connects the pons and the cerebellum with the two cerebral hemispheres. The subarachnoid space lies between the pie matter and the arachnoids membrane.

Which neurons transmit impulses from the CNS? -Sensory -Neurilemma -Dendrites -Motor

-motor -Neurons are either sensory or motor. Sensory neurons transmit impulses to the CNS; motor neurons transmit impulses from the CNS. A membranous sheath called the neurilemma covers the myelin of axons in peripheral nerves. Dendrites are threadlike projections or fibers.

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? -observing the reaction of pupils to light -observing the client's response to painful stimulus -using the Romberg test -assessing the client's sensitivity to temperature, touch, and pain

-observing the client's response to painful stimulus The nurse evaluates motor response in a comatose or unconscious client by administering a painful stimulus. This action helps determine if the client makes an appropriate response by reaching toward or withdrawing from the stimulus. The Romberg test is used to assess equilibrium in a noncomatose client. Pupils are examined for their reaction to light to assess sensitivity in the third cranial (oculomotor) nerve. Sensitivity to temperature, touch, and pain is a test to assess the sensory function of the client and not motor response.

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- 0 2- 1+ 3- 2+ 4- 3+

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? 1- 0 2- 1+ 3- 2+ 4- 3+

1+

Which term refers to the inability to coordinate muscle movements, resulting in difficulty walking? 1- Agnosia 2- Ataxia 3- Spasticity 4- Rigidity

2- Ataxia

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? Select all that apply. 1- Hyper-reactive deep tendon reflexes 2- Decreased muscle mass 3- Increased sensitivity to heat and cold 4- Stage IV sleep is prolonged 5- Increased sensitivity of taste buds 6- Reduced papillary responses

2- Decreased muscle mass 3- Increased sensitivity to heat and cold 6- Reduced papillary responses

Which term refers to the inability to coordinate muscle movements, resulting difficulty walking? 1- Agnosia 2- Ataxia 3- Spasticity 4- Rigidity

Ataxia

Which of the following terms is used to describe rapid, jerky, involuntary, purposeless movements of the extremities? 1- Chorea 2- Bradykinesia 3- Spondylosis 4- Dyskinesia

Chorea

The trochlear nerve controls which function? 1- Movement of the tongue 2- Hearing and equilibrium 3- Visual acuity 4- Eye muscle movement

Eye muscle movement

Which term describes the fibrous connective tissues that cover the brain and spinal cord? 1- Meninges 2- Dura mater 3- Arachnoid mater 4- Pia mater

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? 1- III 2- IV 3- V 4- VI

V

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? 1- V (Trigeminal) 2- VI (Abducens) 3- VII (Facial) 4- IV (Trochlear)

VI (Abducens)

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? 1- VIII 2- X 3- III 4- VII

X

A nurse has assessed a patient's orientation during the initial head-to-toe assessment near the beginning of a shift. The patient is able to state his own full name and knows the name of the hospital but is unable to identify the month and the year. How should the nurse best document this assessment finding? 1- "Patient is demonstrating signs of decreased neurological function." 2- "Patient is disoriented." 3- "Patient is oriented to person and place, but unable to state month and year." 4- "Patient is oriented to person, oriented to place, but not oriented to time."

"Patient is oriented to person and place, but unable to state month and year."

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? 1- "There is a very weak familial tendency." 2- "No familial tendency has been demonstrated." 3- "There is a strong familial tendency." 4- "Only secondary migraine headaches show a familial tendency."

"There is a strong familial tendency."

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? 1- "What city and state are we in right now?" 2- "What would you do if you found a stamped envelope on the street?" 3- "If you divide 16 by four and then double it, what do you get?" 4- "How do you believe that Alzheimer's disease is affecting you?"

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

The nurse is caring for a client who is to have a lumbar puncture. What are the lowest vertebrae that contain the spinal cord? -Coccyx -Second lumbar vertebrae -Eleventh thoracic vertebrae -Fifth lumbar vertebrae

-Second lumbar vertebrae

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: 1- 20 2- 15 3- 10 4- 5

15

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: 1- Benign spinal cord lesions 2- Cranial nerve deficits 3- Abnormal activity in the cerebral cortex 4- Faulty integration of sensory impulses by the thalamus

Abnormal activity in the cerebral cortex

The nurse is admitting a patient to the unit who is diagnosed with a lower motor neuron lesion. What clinical manifestations would this patient most likely exhibit? 1- Increased muscle tone 2- No muscle atrophy 3- Hyperactive and abnormal reflexes 4- Absent or decreased reflexes

Absent or decreased reflexes

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 1 Visual agnosia 2 A positive Romberg 3 Ataxia 4 Astereognosis

Astereognosis

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? 1- Frontal lobe 2- Occipital lobe 3- Parietal lobe 4- Brain stem

Brain stem

The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart? 1- CN I 2- CN II 3- CN III 4- CN IV

CN II

A nurse is assessing reflexes in a patient with hyperactive reflexes. When the patient's foot is abruptly dorsiflexed, it continues to "beat" two to three times before setting into a resting position. How would the nurse document this finding? 1- Rigidity 2- Flaccidity 3- Clonus 4- Ataxia

Clonus

The critical care nurse is giving end-of-shift report on a client she is 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 oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? 1- Comatose 2- Somnolence 3- Stupor 4- Normal

Comatose

The nurse is assessing the pupils of a patient who has had a head injury. What does the nurse recognize as a parasympathetic effect? 1- Dilated pupils 2- Constricted pupils 3- One pupil is dilated and the opposite pupil is normal 4- Roth's spots

Constricted pupils

There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected with decreased visual fields. 1- Cranial nerve I 2- Cranial nerve II 3- Cranial nerve III 4- Cranial nerve IV

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? 1- Cranial nerve I 2- Cranial nerve V 3- Cranial nerve XI 4- Cranial nerve XII

Cranial nerve XII

Which of the following is a sympathetic nervous system effect? 1- Decreased peristalsis 2- Decreased blood pressure 3- Constricted pupils 4- Constricted bronchioles

Decreased peristalsis

A patient has a deficiency of the neurotransmitter serotonin. The nurse is aware that this deficiency can lead to: Myasthenia gravis. Depression. Seizures. Parkinson's disease.

Depression. Serotonin helps control mood and sleep. A deficiency leads to 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? 1- Dysfunction of the spinal accessory nerve 2- Dysfunction of the acoustic nerve 3- Dysfunction of the facial nerve 4- Dysfunction of the vagus nerve

Dysfunction of the vagus nerve

Which safety action will the nurse implement for a client receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)? 1- Securely fasten the client's portable oxygen tank to the bottom of the MRI table after the client has been positioned on the table. 2- Check the client's oxygen saturation level using a pulse oximeter after the client has been placed on the MRI table. 3- Note that no special safety actions need to be taken. 4- Ensure that no client care equipment containing metal enters the room where the MRI table is located.

Ensure that no client 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? 1- Abnormal posture 2- Flaccidity 3- Weak muscular tone 4- Decorticate posturing

Flaccidity

Which cerebral lobes is the largest and controls abstract thought? 1- Temporal 2- Frontal 3- Parietal 4- Occipital

Frontal

Which lobe of the brain is responsible for concentration and abstract thought? 1- Frontal 2- Parietal 3- Temporal 4- Occipital

Frontal

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? 1- Frontal lobe 2- Parietal lobe 3- Occipital lobe 4- Temporal lobe

Frontal lobe

Cranial nerve IX is also known as which of the following? 1- Glossopharyngeal 2- Vagus 3- Spinal accessory 4- Hypoglossal

Glossopharyngeal

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? 1- Myelogram 2- Electroencephalogram 3- Echoencephalography 4- Glossopharyngeal

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? 1- Head of the bed elevated 45 degrees 2- Prone 3- Supine with feet raised 4- Supine with the head lower than the trunk

Head of the bed elevated 45 degrees

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: 1- Fine movements. 2- Sleep patterns. 3- Heart rate and rhythm. 4- Emotional balance.

Heart rate and rhythm.

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? 1- Ataxic 2- Dystrophic 3- Helicopod 4- Steppage

Helicopod

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure? 1- Prone, with the head turned to the right 2- Supine, with the knees raised toward the chest 3- Lateral recumbent, with chin resting on flexed knees 4- Lateral, with right leg flexed

Lateral recumbent, with chin resting on flexed knees

A client presents to the emergency department status post-seizure. The physician wants to know what the pressure is in the client's head. What test might be ordered on this client? 1- Lumbar puncture 2- Echoencephalography 3- Nerve conduction studies 4- EMG

Lumbar puncture

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? 1- Older adults tend to have a blunted pain sensation, so complaints should be followed-up promptly. 2- Older adults frequently confuse pain with other tactile sensations. 3- Pain in older adults is often unrelated to physical harm or pathophysiological processes. 4- The sensation of pain increases with age, so older adults typically feel more pain for a longer period than younger patients.

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

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? 1- Central 2- Sympathetic 3- Peripheral 4- Parasympathetic

Parasympathetic

Which lobe of the brain is responsible for spatial relationships? 1- Parietal 2- Temporal 3- Occipital 4- Frontal

Parietal

A nurse conducts the Romberg test by asking the client to stand with the feet close together and the eyes closed. As a result of this posture, the client suddenly sways to one side and is about to fall when the nurse intervenes and prevents the client from being injured. In which way should the nurse interpret the client's result? 1- Positive Romberg test, indicating a problem with level of consciousness 2- Negative Romberg test, indicating a problem with body mass 3- Negative Romberg test, indicating a problem with vision 4- Positive Romberg test, indicating a problem with equilibrium

Positive Romberg test, indicating a problem with equilibrium

A nursing educator is talking with nurses about the effects of the aging process and neurologic changes. What would the educator identify as a normal neurological change that accompanies the aging process? 1- Hyperactive deep tendon reflexes 2- Reduction in cerebral blood flow (CBF) 3- Increased cerebral metabolism 4- Hypersensitivity to painful stimuli

Reduction in cerebral blood flow (CBF)

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? 1- Risk for aspiration 2- Risk for falls 3- Risk for impaired skin integrity 4- Decreased intracranial adaptive capacity

Risk for aspiration

A critical care nurse is documenting her assessment of a client she is caring for. The client is status post-resection of a brain tumor. The nurse documents that the client is flaccid on the left. What does this mean? 1- The client has an abnormal posture response to stimuli. 2- The client is not responding to stimuli. 3- The client is hyperresponsive on the left. 4- The client is hyporesponsive on the left.

The client is not responding to stimuli.

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? 1- The patient's weakness is most severe in the early morning. 2- The weakness is primarily on the left side of the patient's body. 3- The weakness is not relieved by increasing her food intake. 4- The patient's weakness began around the time of her husband's death.

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

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? 1- VIII 2- X 3- III 4- VII

VIII

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? 1- Proximity to the CT scanner 2- Variations in tissue density 3- Metabolic activity 4- Oxygen consumption

Variations in tissue density

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? 1- IV 2- IX 3- VI 4- XII

XII

A nurse is working in a neurologist's office. The physician orders a Romberg test. The nurse should have the client: 1- touch his or her nose with one finger. 2- close his or her eyes and stand erect. 3- close his or her eyes and discriminate between dull and sharp. 4- close his or her eyes and jump on one foot.

close his or her 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, the nurse anticipates that the liver will: 1- cease function and shunt blood to the heart and lungs. 2- convert glycogen to glucose for immediate use. 3- produce a toxic byproduct in relation to stress. 4- maintain a basal rate of functioning.

convert glycogen to glucose for immediate use.

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 cerebrum. -risk for increased intracranial pressure. -dysfunction in the brain stem. -dysfunction in the spinal column.

dysfunction in the brain stem. Decerebrate posturing indicates damage of the upper brain stem. Decorticate posturing indicates cerebral dysfunction. Increased intracranial pressure is a cause of decortication and decerebration. Alterations in sensation or paralysis indicate dysfunction in the spinal column.

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? 1- frontal 2- parietal 3- temporal 4- occipital

occipital

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 1- refrain from eating or drinking for now. 2- have their spouse bring in the client's glasses. 3- wear any hearing aids while in the hospital. 4- use the walker when walking.

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: 1- identification of information due to slowed passages of information to brain. 2- cognitive ability to understand relayed information. 3- processing information transferred from the environment. 4- response due to interrupted impulses from the central nervous system

response due to interrupted impulses from the central nervous system

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: 1- introducing ice water into the external auditory canal. 2- touching the cornea with a wisp of cotton. 3- turning the client's head suddenly while holding the eyelids open. 4- shining a bright light into the pupil.

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

A nurse is conducting a neurological assessment of a patient who has just been admitted to the unit. In preparation for assessing the patient for pronator drift, what instructions should the nurse provide to the patient? 1- "Please hold your arms straight out with your palms pointing up to the ceiling." 2- "Please close your eyes and then walk a few steps with one foot directly in front of the other." 3- "Please close your eyes and then touch the tip of your nose with one index finger and then the other." 4- "Please lift one leg a few inches off the bed and hold it as still as possible."

"Please hold your arms straight out with your palms pointing up to the ceiling."

The cerebral circulation receives approximately what percentage of the cardiac output? -15% -10% -25% -20%

-15% The cerebral circulation receives approximately 15% of the cardiac output, or 750 mL per minute.

Which of the following neurotransmitters are deficient in myasthenia gravis? -Acetylcholine -GABA -Dopamine -Serotonin

-Acetylcholine A decrease in the amount of acetylcholine causes myasthenia gravis. A decrease of serotonin leads to depression. Parkinson's disease is caused by a depletion of dopamine. Decreased levels of GABA may cause seizures.

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 pons -In the medulla oblongata -In the spinal cord -In the midbrain

-In the spinal cord The spinal cord functions as a passageway for ascending sensory and descending motor neurons. Its two main functions are to provide centers for reflex action and to serve as a pathway for impulses to and from the brain. Reflex centers are not in the pons, the medulla, or the midbrain.

What part of the brain controls and coordinates muscle movement? 1- Cerebellum 2- Cerebrum 3- Midbrain 4- Brain stem

Cerebellum

A nurse is discussing a lumbar puncture with a nursing student who observed the procedure. The student noticed that the cerebrospinal fluid was blood tinged and asks what that means. The correct reply is which of the following? -"It can mean a traumatic puncture or a subarachnoid bleed." -"It can mean a bleed around the hypothalamus or damage from the needle." -"It can mean the spinal cord was damaged or a traumatic puncture." -"It can mean a subarachnoid bleed or damage to the spinal cord."

-"It can mean a traumatic puncture or a subarachnoid bleed." The needle is inserted below the level of the spinal cord, which prevents damage to the cord. The cerebral spinal fluid (CSF) should be clear and colorless. Pink or bloody CSF may indicate a subarachnoid bleed or local trauma from the puncture. The hypothalamus is located deep inside the brain and does not affect the color of the CSF.

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? -Headache and pain in the neck -Claustrophobia -Allergic reaction to the imaging material -Allergic reaction to radioactive rays

-Allergic reaction to the imaging material

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? -Early ambulation -Have the patient lie flat for 6 hours. -Have the patient lie flat for 1 hour and then sit for 1 hour before ambulating. -Have the patient lie in a semi-Fowler's position with the head of the bed at 30º.

-Have the patient lie flat for 6 hours. Post-lumbar puncture headache may be avoided if a small-gauge needle is used and if the patient remains prone after the procedure. When more than 20 mL of CSF is removed, the patient is positioned supine for 6 hours (Bader & Littlejohns, 2010).

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 toward both sides -Lightly tapping the lower portion of the neck to detect sensation -Moving the head and chin toward the chest -Gently pressing the bones on the neck

-Moving the head and chin toward the chest The neck is examined for stiffness or abnormal position. The presence of rigidity is assessed by moving the head and chin toward the chest. The nurse should not maneuver the neck if a head or neck injury is suspected or known. The neck should also not be maneuvered if trauma to any part of the body is evident. Moving the head toward the sides or pressing the bones on the neck will not help assess for neck rigidity correctly. While assessing for neck rigidity, sensation at the neck area is not to be assessed.

The nurse is caring for a client in the clinic who has come in to have an EMG done. How would the nurse prepare the client for this test? -Tell the client the doctor will use fluoroscopy for this test. -Tell the client the test is painless. -Tell the client to expect some discomfort. -Tell the client they will have to lie flat afterwards.

-Tell the client to expect some discomfort. Tell the client to expect some discomfort when undergoing a lumbar puncture, myelogram, EMG, or nerve conduction studies. There is no fluoroscopy used for an EMG. It is not necessary to lie flat after an EMG.

During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to: -use the pointed end of the reflex hammer when striking the Achilles tendon. -support the joint where the tendon is being tested. -tap the tendon slowly and softly. -hold the reflex hammer tightly.

-support the joint where the tendon is being tested. The nurse should support the joint where the tendon is being tested to prevent the attached muscle from contracting. The nurse should use the flat, not pointed, end of the reflex hammer when striking the Achilles tendon. (The pointed end is used to strike over small areas, such as the thumb placed over the biceps tendon.) Tapping the tendon slowly and softly wouldn't provoke a deep tendon reflex response. The nurse should hold the reflex hammer loosely, not tightly, between the thumb and fingers so it can swing in an arc.

When learning about the nervous system, students learn that which nervous system regulates the expenditure of energy? 1- Parasympathetic 2- Central 3- Peripheral 4- Sympathetic

Sympathetic

Lower motor neuron lesions cause 1- increased muscle tone. 2- flaccid muscles. 3- no muscle atrophy. 4- hyperactive and abnormal reflexes.

flaccid muscles.

To assess a client's cranial nerve function, a nurse should assess: 1- hand grip. 2- orientation to person, time, and place. 3- arm drifting. 4- gag reflex.

gag reflex.

A nurse is preparing a client for a lumbar puncture and informs the client that the needle will be inserted into the subarachnoid space between L3 and L4 or L4 and L5. The client reports that she is worried about damage to her spinal cord. The appropriate response from the nurse is which of the following? -"The spinal cord ends at L1, so puncturing it is not possible." -"Damage to the spinal cord is a possibility." -"The physician is careful not to insert the needle far enough to reach the cord." -"The needle is not long enough to damage the cord."

-"The spinal cord ends at L1, so puncturing it is not possible." The needle is usually inserted into the subarachnoid space between the 3rd and 4th or 4th and 5th lumbar vertebrae. Because the spinal cord ends at the 1st lumbar vertebra, insertion of the needle below the level of the 3rd lumbar vertebra prevents puncture of the spinal cord.

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? -Blood vessels in the heart muscle to dilate -Heartbeat to decrease -Blood pressure to increase -Blood vessels in the skeletal muscles to dilate

-Blood vessels in the heart muscle to dilate The parasympathetic nervous system has a constricting effect on the blood vessels in the heart and skeletal muscles; the heartbeat and blood pressure will decrease.

Which cranial nerve is responsible for facial sensation and corneal reflex? -Oculomotor -Vestibulocochlear -Facial -Trigeminal

-Trigeminal The trigeminal (V) cranial nerve is also responsible for mastication. The oculomotor (III) cranial nerve is responsible for the muscles that move the eye and lid, pupillary constriction, and lens accommodation. The vestibulocochlear (VII) cranial nerve is responsible for hearing and equilibrium. The facial nerve is responsible for salivation, tearing, taste, and sensation in the ear.

The nurse is doing an initial assessment on a patient recently admitted to the unit with a diagnosis of cerebrovascular accident (CVA). The patient has difficulty copying a figure that the nurse has drawn. The nurse uses this technique to assess for what type of aphasia? 1- Auditory-receptive 2- Visual-receptive 3- Expressive speaking 4- Expressive writing

Visual-receptive

The brain stem holds the medulla oblongata. What is the function of the medulla oblongata? -transmits sensory impulses from the brain to the spinal cord -controls striated muscle activity in blood vessel walls -controls parasympathetic nerve impulses in the pons -transmits motor impulses from the brain to the spinal cord

-transmits motor impulses from the brain to the spinal cord The medulla oblongata lies below the pons and transmits motor impulses from the brain to the spinal cord and sensory impulses from peripheral sensory neurons to the brain. The medulla contains vital centers concerned with respiration, heartbeat, and vasomotor activity (the control of smooth muscle activity in blood vessel walls).

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. -Provide the client with adequate caffeine-rich drinks. -Measure the level of consciousness (LOC) of the client. -Measure the heart and the pulse rate.

-Allow the client to rest and shampoo the client's hair. After an EEG, the nurse should ensure rest for the sleep-deprived client and shampoo the client's hair to remove the glue used to affix electrodes to the scalp. The client is advised not to take sedative drugs and caffeine-related drinks before the EEG, and there is no reason to provide the client with them after the test. The nurse should not measure the LOC, the heart rate, or the pulse rate of the client unless advised by the physician.

Which diagnostic procedure would the nurse anticipate performing first if the goal was to obtain a thin "slice" of a muscular body area? -Computed tomography (CT) -Magnetic resonance imaging (MRI) -Positron emission tomography (PET) -Single-photon emission computed tomography (SPECT)

-Computed tomography (CT) A computer tomography scan uses x-rays and computer analysis to produce three-dimensional views of cross sections, or "slices," of the body. An MRI uses radiofrequency waves to produce images of tissue. PET scans use radioactive substances to examine metabolic activity and organ involvement. SPECT is an imaging tool that examines cerebral blood flow.

The nurse is educating a group of people newly diagnosed with migraine headaches. What information should the nurse include in the educational session? Select all that apply. 1- Keep a food diary. 2- Maintain a headache diary. 3- Sleep no more than 5 hours at a time. 4- Exercise in a dark room. 5- Use St. John's Wort.

1- Keep a food diary. 2- Maintain a headache diary.

A client suspected of having a distortion of cerebral arteries and veins is scheduled for a cerebral angiography. What would the nurse tell the client about the upcoming test? -That sedatives, coffee, tea, and soft drinks that contain caffeine will be withheld for at least 8 hours before the test to avoid affecting the diagnostic findings. -The client will have to stay in a dark quiet room. -Contrast will be given and a rapid sequence of radiographs will be taken. -The client will have to shampoo his or her hair.

-Contrast will be given and a rapid sequence of radiographs will be taken. A radiopaque dye is injected into the right or left carotid artery, the brachial artery, or the femoral artery. A rapid sequence of radiographs is taken as the dye circulates through the cerebral arteries and veins. For cerebral angiography options A, B, and D do not apply.

Damage to which area of the brain results in receptive aphasia? -Parietal lobe -Occipital lobe -Temporal lobe -Frontal lobe

-Temporal lobe The temporal lobe contains the auditory association area. If the area is damaged in the dominant hemisphere, the client hears words but doesn't know their meanings. Damage to the parietal lobe affects the client's ability to identify special relationships with the environment. When damaged, the occipital lobe affects visual associations. The client can visualize objects but can't identify them. The frontal lobe acts as a storage area for memory.

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? -Acetone -A special soap -Shampoo -Warm water

-Shampoo Explanation: Shampoo is used to remove the paste, which attached the electrodes to the head. Acetone is not used on the hair. There is no special soap needed. More than warm water is needed to lift and remove the paste.

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: -hypoxia. -fever. -visual disturbance. -gait alteration.

-hypoxia. Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing, and coughing. Therefore, the nurse should monitor the client closely for hypoxia. Temperature control, vision, and gait aren't lower brain stem functions.

A primary nursing assessment for a patient who has sustained a fracture involving the basilar skull is inspection for: 1- Leakage of CSF from the nose. 2- Ecchymosis of the mastoid process of the temporal bone. 3- Leakage of CSF from the ear. 4- Vomiting and headaches due to increased intracranial pressure.

Leakage of CSF from the ear.

Which neurotransmitter demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways? 1- Enkephalin 2- Norepinephrine 3- Acetylcholine 4- Serotonin

Serotonin

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? 1- Left frontoparietal region 2- Right frontoparietal region 3- Left basal ganglia 4- Left temporal region

Left frontoparietal region

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? 1- Administer antihistamines to the client. 2- Provide adequate caffeine-rich drinks to the client. 3- Assess the level of consciousness (LOC) and the pupil response of the client. 4- Position the client flat for at least 3 hours.

Position the client flat for at least 3 hours.

A client is scheduled for an EEG. The client asks about any diet-related prerequisites before the EEG. Which diet-related advice should the nurse provide to the client? 1- Avoid eating food at least 8 hours before the test. 2- Include an increased amount of minerals in the diet. 3- Decrease the amount of minerals in the diet. 4- Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours before the test.

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