N136 MCA-2 Week 4 Neurologic and Sensory Systems

The nurse observes dorsiflexion of the big toe and farming of other toes when the lateral side of a client's foot is stroked. Which finding would the nurse document? 0 'Has intact plantar reflexes' O 'Exhibits a positive Babinski sign' 0 'Demonstrates normal sensory function' 0 'Able to perform active range of motion'

'Exhibits a positive Babinski sign' This is a positive Babinski sign; it is expected in infants but suggests upper motor neuron disease of the pyramidal tract in adults. The plantar reflex involves flexion of the toes and plantar flexion of the feet. 'Demonstrates normal sensory function' is incorrect; positive Babinski is not an indication of normal sensation. 'Able to perform active range of motion is inaccurate'; Babinski reflex is not caused by intentional movement. Active range of motion is a type of exercise, not a reflex.

After a discectomy and fusion surgery, the client wants to attempt walking with assistance for the first time. Upon rising to a standing position, the client reports feeling faint and light headed. Which action would the assisting nurse have the client do upon hearing the client's concern? 0 Have the client sit on the edge of the bed so the nurse can hold the client upright. Q Have the client slide to the floor with assistance to avoid injuring the client because of a fall. 0 Have the client bend forward to increase blood flow to the brain. 0 Have the client lie down immediately so the nurse may obtain the client's blood pressure (BP).

0 Have the client sit on the edge of the bed so the nurse can hold the client upright. Sitting maintains alignment of the back and allows the nurses to support the client until orthostatic hypotension subsides. Sliding to the floor and bending forward will induce flexion of the vertebrae, which can traumatize the spinal cord. Rapid movement can flex the vertebrae, which will traumatize the spinal cord; taking the BP at this time is not necessary. Test-Taking Tip: Many times the correct answer is the longest alternative given, but do not count on it. Item writers (those who write the questions) are also aware of this and attempt to avoid offering you such 'helpful hints.'

The nurse is teaching the client about cerumen when irrigating the ear. Which area will the nurse indicate to the client in the given image that is an example of cerumen? Q 1 Q 2 Q 3 Q 4

2 Option 2 indicates cerumen. Option 1 indicates the pinna. Option 3 indicates the tympanic membrane. Option 4 indicates the ear canal.

Which muscle in the given figure turns the eye toward the nose? 1 2 3 4

2 Option 2 indicates the medial rectus muscle, which turns the eye toward the nose and helps in contraction. Option 1 indicates the superior rectus muscle, which moves the eye diagonally upward toward the side and middle of the head. Option 3 indicates the lateral rectus muscle, which holds the eye straight and turns the eye toward the side of the head. Option 4 indicates the inferior rectus muscle, which moves the eye diagonally downward toward the side and middle of the head.

A 50-year-old client has difficulty communicating because of expressive aphasia after a cerebrovascular accident (CVA, also known as a 'brain attack'). When the nurse inquired about the client's feelings, the spouse responded. Which communication strategy would the nurse use to address this behavior? 0 Ask the spouse how to know the client's feelings. O Instruct the spouse to let the client answer. Q When the spouse leaves, return to speak with the client. 0 Acknowledge the spouse, but look at the client for a response.

Acknowledge the spouse, but look at the client for a response. The client must have the opportunity to practice language skills; family participation must be accepted and recognized. The spouse should be included and involved in the client's care. Asking the wife how she knows the client's feelings, instructing the wife to let the client answer for himself, and returning to speak with the client when the wife leaves, demeans the spouse and cuts off communication. STUDY TIP: Record the information you find to be most difficult to remember on 3' x 5' cards and carry them with you in your pocket or purse. When you are waiting in traffic or for an appointment, just pull out the cards and review again. This 'found' time may add points to your test scores that you have lost in the past.

Which action would the nurse confirm before approving a client's transfer to radiology for magnetic resonance imaging (MRI)? 0 The client received the scheduled preprocedure medications. 0 All metal objects, such as jewelry, hair ornaments, and clothing containing metal were removed. 0 Infusion of intravenous (IV) fluids completed per the preprocedure hydration protocol. 0 The client emptied the bladder, donned a gown that which opens in the front, and removed underwear.

All metal objects, such as jewelry, hair ornaments, and clothing containing metal were removed. The client must remove all metal before entering the MRI area because the MRI emits a strong magnetic field. All scheduled medications may not be necessary before the test. Pre—hydration is not necessary for an MRI and may cause interruptions for the client to void. Testing with contrast requires pre-hydration, such as computed tomography scans. The client should have the opportunity to void before going for the test. The direction in which the client's gown opens is not a concern. Underwear is removed only if there are metal objects, such as an underwire bra. STUDY TIP: Try to decrease your workload and maximize your time by handling items only once. Most of us spend a lot oftime picking up things we put down rather than putting them away when we have them in hand. Going straight to the closet with your coat when you come in instead ofthrowing it on a chair saves you the time of hanging it up later. Discardingjunk mail immediately and filing the rest ofyour bills and mail as they come in rather than creating an ever—growing stack saves time when you need to find something quickly. Filing all items requiring further attention in some fashion helps you remember to take care ofthings on time rather than being so engrossed in your schoolwork that you forget about them. Many nursing students have had their power or telephone service cut off because the bill simply was forgotten or buried in a pile of old mail.

Which part of the brain is primarily associated with life support and basic functions of the body? O Cerebrum Q Brainstem O Cerebellum Q Cerebral cortex

Brainstem The brainstem, which connects the brain to the central nervous system, is concerned primarily with life support and basic functions, such as breathing and movement. The cerebrum controls intelligence, creativity, and memory. The cerebellum is concerned with coordination of movement. The cerebral cortex is part of the cerebrum, which is involved with almost all of the higher functions of the brain.

Which test is used to diagnose diseases of the vestibular system? Q Rinne test 0 Caloric reflex test 0 Pure—tone audiometry O Auditory brainstem response

Caloric reflex test The caloric reflex test is a test of the vestibulo—ocular reflex that involves irrigating cold or warm water into the external auditory canal. It is used to check for nystagmus, nausea and vomiting, falling, or vertigo, conditions associated with diseases of the vestibular system. The Rinne test is a tuning fork test that aids in differentiating between conductive and sensorineural hearing loss. Pure-tone audiometry determines the client's hearing range in terms of decibels (dB) and Hertz (Hz). This test is used to diagnose conductive and sensorineural hearing loss. An auditory brainstem response test provides diagnostic information related to acoustic neuromas, brainstem problems, and strokes.

Upon assessment, the nurse finds the following (see image). The nurse will prepare the client for which type of surgery? O Keratoplasty O Trabeculoplasty O Cataract removal 0 Laser in situ keratomileusis (LASIK)

Cataract removal The given figure indicates a mature cataract because of increased lens density; surgery (cataract removal) is the only treatment for this defect. Keratoplasty (corneal transplant) is a surgical procedure performed in a client with a misshapen cornea. Trabeculoplasty is the laser surgical technique performed in a client with glaucoma. LASIK is a vision—enhancing surgery performed to correct nearsightedness, farsightedness, and astigmatism.

Which radiologic study is used to obtain three-dimensional brain images? 0 Electromyography O Cerebral angiography O Computed tomography (CT) 0 Transcranial Doppler

Computed tomography (CT) A CT scan provides a rapid means of obtaining radiographic images of the brain to provide a three— dimensional representation of the intracranial contents. Electromyography is used to record electrical activity associated with innervations of skeletal muscle. Cerebral angiography is used to view vascular lesions or tumors. Transcranial Doppler evaluates blood flow velocities of the intracranial blood vessels.

Which action would the nurse test when assessing a client's eyes to ensure formation of a single image of close objects? 0 Mydriasis 0 Convergence 0 Accommodation 0 Pupillary constriction and dilation

Convergence The nurse would be testing for the convergence action of the eyes to determine ifa client sees only a single image of close objects. Mydriasis is pupil dilation and occurs when exposed to reduced light or looking at a distance. The process of maintaining a clear visual image when the client's gaze shifts from a distant object to a near object is accommodation. Pupillary constriction and dilation control the amount oflight that enters the eye.

Which lobe of the cerebrum includes the Broca speech center? Q Frontal lobe Q Parietal lobe Q Occipital lobe Q Temporal lobe

Frontal lobe The Broca speech center is located in the frontal lobe and is responsible for the formation ofwords into speech. The parietal lobe aids in processing of spatial awareness and receiving and processing information about temperature, taste, and touch. The primary visual center is in the occipital lobe. The auditory center for interpreting sound is present in the temporal lobe.

The nurse is interviewing a client with a tentative diagnosis of Parkinson disease. Which description would the nurse give to the client about the onset of symptoms? 0 Suddenly Q Gradually 0 Overnight Q irregularly

Gradually The onset ofthis disease is not sudden, but rather insidious, with a prolonged course and gradual progression. The onset is slow and gradual. The onset is not irregular; there is a gradual, regular progression of symptoms.

Which condition is associated with involuntary and rapid twitching of the eyeball? O Ptosis Q Anisocoria O Nystagmus O Enophthalmos

Nystagmus Nystagmus is characterized by an involuntary and rapid twitching of the eyeball. Ptosis is characterized by drooping of eyelids. Anisocoria is characterized by a normally noticeable difference in the size of the pupils and is a normal finding in 5% of the population. Enophthalmos is characterized by the sunken appearance of the eye.

Which visual system assessment technique provides a magnified view of the retina and optic nerve head? 0 Keratometry O Ophthalmoscopy 0 Visual acuitytesting O Confrontation visual filed test

Ophthalmoscopy Ophthalmoscopy provides a magnified view of the retina and optic nerve head. Keratometry measures corneal curvature. Visual acuity testing determines distance and near vision acuity. The confrontation visual field test determines ifa client has a full field ofvision without obvious scotomas.

Which type of nerve helps the client's pupil constrict? 0 Motor 0 Sensory O Sympathetic O Parasympathetic—motor

Parasympathetic—motor The parasympathetic-motor nerves located in the midbrain help in pupil constriction. The motor nerves help in eye movement. The sensory nerves help in sensory perception. The sympathetic nerves help in involuntary functions of the body.

Which type of rehabilitation is an essential component to a client's recovery from Guillain-Barré syndrome? 0 Physical therapy 0 Speech exercises O Fitting with a vertebral brace O Follow-up on cataract progression

Physical therapy Rehabilitation needs for a client with Guillain-Barré syndrome focuses on physical therapy and exercise for the lower extremities because of muscle weakness and discomfort. A client with Guillain-Barré syndrome does not need speech or swallowing exercises. A client with Guillain—Barré syndrome does not need vertebral support. Problems with cataracts are not associated with Guillain-Barré syndrome. Test-Taking Tip: Monitor questions that you answer with an educated guess or changed your answer from the first option you selected. This will help you analyze your ability to think critically. Usually your first answer is correct, and you should not change the answer without reason.

Punctal occlusion is performed after the administration of eyedrops to prevent which from occurring? 0 Tearing 0 Infection 0 Allergic reaction 0 Systemic absorption

Systemic absorption Punctal occlusion prevents systemic absorption of the medication. For example, systemic absorption of beta— blockade used to treat glaucoma can affect heart rate and blood pressure. Punctal occlusion does not prevent tearing, infection, or allergic reaction.

Which medication is a beta-adrenergic blocker used to reduce intraocular pressure? 0 Timolol O Travoprost O Carbachol O Apraclonidine

Timolol Glaucoma is manifested by increased intraocular pressure. Timolol is a beta-adrenergic blocker used in the treatment of glaucoma. Carbachol is a cholinergic agonist used to treat glaucoma. Travoprost is a prostaglandin agonist, and apraclonidine is an adrenergic agonist used in the treatment of glaucoma.

Which nursing action has the highest priority when preparing to transfer an unconscious client who sustained a head injury from the emergency department to a neurological trauma unit? 0 Notifying the receiving unit of the transfer 0 Having the client's records ready for the transfer 0 Verifying that the family has been notified of the transfer 0 Validating availability of a bag-valve-mask during the transfer

Validating availability of a bag-valve-mask during the transfer Validating availability of a bag—valve-mask during the transfer is vital in case of respiratory distress; increased intracranial pressure compresses the brainstem, which contains the medulla, the respiratory center. Notifying the receiving unit of the transfer is important, but not of primary urgency; the respiratory status is the priority. Having the client's records ready for the transfer is important, but not of primary urgency; the respiratory status is the priority. Verifying notification of the family regarding the transfer is important, but not of primary urgency; the respiratory status is the priority. Test-Taking Tip: On a test day, eat a normal meal before going to school. If the test is late in the morning, take a high-powered snack with you to eat 20 minutes before the examination. The brain works best when it has the glucose necessary for cellular function.

After a cerebrovascular accident (CVA, also known as 'brain attack'), a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. The nurse would conclude the CVA affected which lobe of the brain? 0 Frontal O Parietal O Occipital 0 Temporal

Parietal Sensory impulses from temperature, touch, and pain travel via the spinothalamic pathway to the thalamus and then to the postcentral gyrus of the parietal lobe, the somatosensory area. The frontal area is the area of abstract thinking and muscular movements. The occipital area of the brain is where nerve impulses translate into sight. The temporal area is the area where nerve impulses translate into sound.

Which clinical manifestations indicate a client who sustained head and chest injuries from a motor vehicle accident, responded to medical treatments, and is ready for transfer to a critical care unit? 0 Stabilized vital signs and complaints of pain 0 Pale and alert; remains restless 0 Increasing temperature and apprehension O Fluctuating vital signs and drowsy, but easily roused

Stabilized vital signs and complaints of pain Stable vital signs is the major indicator predicting transfer will not jeopardize the client's condition. Although complaints of pain are a concern, they do not place the client in physiologic jeopardy. Restlessness and pallor may be early signs of shock; the client needs further assessment. An increasing temperature is a sign of increasing intracranial pressure; delay transfer of the client at this time. Fluctuating vital signs and drowsiness indicate an unstable client with potentially increasing intracranial pressures.

Which action elicits the brachioradialis reflex? O Striking the triceps tendon above the elbow O Striking the radius 3 to 5 cm above the wrist O Striking the patellar tendon just below the patella O Striking the Achilles tendon when the client's leg is flexed

Striking the radius 3 to 5 cm above the wrist The brachioradialis reflex can be elicited by striking the radius 3 to 5 cm above the wrist while the client's arm is relaxed. Striking the triceps tendon above the elbow elicits the triceps reflex. Striking the patellar tendon just below the patella elicits the patellar reflex. Striking the Achilles tendon elicits the Achilles tendon reflex when the client's leg is flexed.

A client with hemiparesis voices a reluctance to use a cane. Which rationale would the nurse use to explain the cane's purpose to the client? 0 Maintain balance to improve stability 0 Relieve pressure on weight—bearing joints O Prevent further injury to weakened muscles 0 Aid in controlling involuntary muscle movements

0 Maintain balance to improve stability Hemiparesis creates instability. Using a cane provides a wider base of support and therefore greater stability. Hemiparesis affects muscle strength on one side of the body; the joints are not directly affected. Activity should strengthen, not injure, weakened muscles. The use of a cane will not prevent involuntary movements if they are present. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Example: if you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low—fat, high—protein, low—calorie diet).

A client with myasthenia gravis experiences generalized weakness. Which nursing intervention would the nurse integrate into the client's plan of care? 0 Maintain strict bed rest for this client. 0 Provide the client frequent rest periods. 0 Reassure the client there are many other tasks awaiting him or her. 0 Arrange for a relative to be present with the client.

0 Provide the client frequent rest periods. Spacing activities encourages maximum functioning within the limits of the client's strength and fatigue. The client should avoid bed rest and limited activity because doing so may lead to muscle atrophy and calcium depletion. Although pointing out things the client can do is important, this does not address the client's concerns. Arranging for a relative to be present is unnecessary if the nursing staff observes the client closely. However, permit visitors if requested by the client or family. Test-Taking Tip: Key words or phrases in the stem of the question such asfirst, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care.

A recently hospitalized client with multiple sclerosis voices a concern about generalized weakness and fluctuating physical status. Which nursing intervention is the priority for this client? 0 Encourage bed rest for this client. 0 Space activities throughout the day. 0 Teach the limitations imposed by the disease. 0 Have one of the client's relatives stay at the bedside.

Space activities throughout the day. Spacing activities will encourage maximum functioning within the limits of strength and fatigue. Bed rest and limited activity may lead to muscle atrophy and calcium depletion. Stress the client's strengths, rather than limitations. Having one of the client's relatives stay at the bedside is unnecessary. The nurse's responsibility is to maintain client safety and meet client needs. Test-Taking Tip: Practicing a few relaxation techniques may prove helpful on the day of an examination. Relaxation techniques such as deep breathing, imagery, head rolling, shoulder shrugging, rotating and stretching of the neck, leg lifts, and heel lifts with feet flat on the floor can effectively reduce tension while causing little or no distraction to those around you. It is recommended that you practice one or two of these techniques intermittently to avoid becoming tense. The more anxious and tense you become, the longer it will take you to relax.

Which action would the nurse take for a client who is having a tonic-clonic seizure? O Elevating the head of the bed 0 Restraining the client's arms and legs 0 Placing a tongue blade in the client's mouth 0 Taking measures to prevent injury

Taking measures to prevent injury Protecting the client from injury is the immediate priority during a seizure. Elevating the head of the bed would have no effect on the client's condition or safety. Restraining the client's arms and legs could cause injury. Placing a tongue blade or other object in the client's mouth could damage the teeth. Test-Taking Tip: After choosing an answer, go back and reread the question stern along with your chosen answer. Does it fit correctly? The choice that grammatically fits the stem and contains the correct information is the best choice.

Which area of the cerebral lobe is linked to Wernicke's area of speech? 0 Limbic lobe Q Frontal lobe Q Parietal lobe Q Temporal lobe

Temporal lobe The temporal lobe consists ofWernicke's area of speech, which helps in the processing ofwords into coherent thought and in understanding written or spoken words. The limbic lobe is involved in regulating emotional patterns, learning, and memory. The frontal lobe is involved in reasoning, concentration, and abstraction. The parietal lobe helps in understanding sensory input, such as texture, size, shape, and spatial relationships.

Which rationale supports the nursing intervention to turn the client with paraplegia every 1 to 2 hours? O To maintain client comfort O To prevent development of pressure injuries O To prevent flexion contractures of the extremities O To improve venous circulation in the lower extremities

To prevent development of pressure injuries Pressure injuries easily develop when maintaining a particular position; the body weight, directed continuously in one region, restricts circulation and results in tissue necrosis. Denervated tissue has less perfusion and is more prone to pressure injuries. Clients often state they are comfortable and wish to remain in one position. More effective measures to prevent contractures include proper positioning with supportive devices and range of motion. Because turning usually occurs laterally, the circulation to the lower extremities is not dramatically affected.

Which group has the highest rate of meningococcal infection? 0 Infants 0 Toddlers 0 Older adults Young adults

Young adults Those between the ages of 16 and 21 years, many ofwhom are young adults, are most at risk for meningococcal infection and are the main target group for vaccination. Infants and toddlers can contract meningococcal infection, but it is not as prevalent in these groups as in the young adult population. Older adults do not have a higher prevalence of meningococcal infection than young adults; however, individuals in this group who are immunocom promised may benefit from receiving the vaccination or boosters. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.