PREP U Ch. 65
A nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm? A. Milligram B. Echoencephalography C. Electroencephalogram D. Cerebral angiography
D. Cerebral angiography The nurse would anticipate a cerebral angiography, which detects distortion of the cerebral arteries and veins .
A patient has difficulty interpreting his awareness of body position in space. Which lobe is most likely to be damaged? A. Temporal B. Parietal C. Occipital D. Frontal
B. Parietal The parietal lobe is the primary sensory cortex. It is essential to a person's awareness of his body in space, as well as orientation in space and spatial relations.
Which term refers to the inability to recognize objects through a particular sensory system? A. Aphasia B. Ataxia C. Agnosia D. Dementia
C. Agnosia Agnosia may be visual, auditory, or tactile. Dementia refers to organic loss of intellectual function. Ataxia refers to the inability to coordinate muscle movements. Aphasia refers to loss of the ability to express oneself or to understand language.
Which term refers to a method of recording, in graphic form, the electrical activity of a muscle? A. Electromyography B. Electrogastrography C. Electroencephalography D. Electrocardiography
A. Electromyography An electromyogram is obtained by inserting needle electrodes into the skeletal muscles to measure changes in the electrical potential of the muscles. Electroencephalography is a method of recording, in graphic form, the electrical activity of the brain. Electrocardiography is performed to assess the electrical activity of the heart. Electrogastrography is an electrophysiologic study performed to assess gastric motility disturbances.
A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in A. Thought content B. Intellectual function C. Motor ability D. Emotional status
A. Thought content Hallucinations are disturbances of thought content. They are not disturbances in motor ability, intellectual function, or emotional status.
A patient has difficulty interpreting his awareness of body position in space. Which lobe is most likely to be damaged? A. Occipital B. Frontal C. Temporal D. Parietal
D. Parietal The parietal lobe is the primary sensory cortex. It is essential to a person's awareness of his body in space, as well as orientation in space and spatial relations.
When learning about the nervous system, students learn that which nervous system regulates the expenditure of energy? A. Peripheral B. Central C. Sympathetic D. Parasympathetic
C. Sympathetic Sympathetic Nervous System: This division of the autonomic nervous system regulates the expenditure of energy.
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? A. Encourage the client to drink liberal amounts of fluid B. Help the client take a brisk walk around the testing area C. Administer antihistamines according to the physicians prescription D. Keep the room brightly lit and have soothing music in the background
A. Encourage the client to drink liberal amounts of fluid The nurse should encourage the client to take liberal fluids and should inspect the injection site for swelling or hematoma. These measures help restore the volume of cerebrospinal fluid extracted.
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 A. Refrain from eating or drinking for now B. Have their spouse bring in the client's glasses C. Wear any hearing aids while in the hospital D. Use the walker when walking
A. Refrain from eating or drinking for now Significant findings of CN IX (glossopharyngeal) include difficulty swallowing (dysphagia) and impaired taste, and significant findings of CN X (vagus) include weak or absent gag reflex, difficulty swallowing, aspiration, hoarseness, and slurred speech (dysarthria). Based on these findings, the nurse should instruct the client to refrain from eating and drinking and should contact the health care provider. The other instructions are associated with abnormalities of CN II (optic) and CN VIII (acoustic).
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: A. Cease function and shunt blood to the heart and lungs B. Convert glycogen to glucose for immediate use C. Maintain a basal rate of functioning D. Produce a toxic byproduct in relation to stress
B. Convert glycogen to glucose for immediate use When the body is under stress, the sympathetic nervous system is activated readying the body for action. The effect of the body is to mobilize stored glycogen to glucose to provide additional energy for body action.
Which neurotransmitter demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways? A. Acetylcholine B. Serotonin C. Norepinephrine D. Enkephalin
B. Serotonin The brain stem, hypothalamus, and dorsal horn of the spinal cord are sources of serotonin.
Which of the following is a sympathetic nervous system effect? A. Constricted pupils B. Decreased BP C. Decreased peristalsis D. Constricted bronchioles
C. Decreased peristalsis Sympathetic effects of the nervous system include decreased peristalsis, increased blood pressure, dilated pupils, and dilated bronchioles.
0 Which is a sympathetic effect of the nervous system? A. Decreased BP B. Increased peristalsis C. Dilated pupils D. Decreased respiratory rate
C. Dilated pupils Dilated pupils are a sympathetic effect of the nervous system, whereas constricted pupils are a parasympathetic effect.
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? A. Temporal lobe B. Parietal lobe C. Frontal lobe D. Occipital lobe
C. Frontal lobe The frontal lobe, the largest lobe, located in the front of the brain. The major functions of this lobe are concentration, abstract thought, information storage or memory, and motor function. It contains Broca's area, which is located in the left hemisphere and is critical for motor control of speech. The frontal lobe is also responsible in large part for a person's affect, judgment, personality, and inhibitions
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? A. CN II B. CN III C. CN IV D. CN I
D. CN I Cranial nerve (CN) I is the olfactory nerve, which allows the sense of smell. Testing of CN I is done by having the patient identify familiar odors with eyes closed, testing each nostril separately. An inability to smell an odor is a significant finding, indicating dysfunction of this nerve.
What part of the brain controls and coordinates muscle movement? A. Cerebellum B. Cerebrum C. Midbrain D. Brain stem
A. Cerebellum The cerebellum, which is located behind and below the cerebrum, controls and coordinates muscle movement.
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? A. IV B. VI C. V D. III
C. V The trigeminal nerve (cranial nerve V) innervates the forehead, cheeks, and jaw, so pain in the face elicited when brushing the teeth would most likely involve this nerve.
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. The nurse would provide further instruction after seeing that the nurse aide: A. Moved the client's head to clean behind the ears B. Cleaned the neck and upper chest area C. Used mild soapy water to clean the face D. Cleaned the eye area from inner to outer area
A. Moved the client's head to clean behind the ears Further instruction would be provided to the nurse aide when the nurse aide attempted to move the client's head to clean behind the ears. There should be no movement of the client's head when there is a history of head trauma.
Lower motor neuron lesions cause A. Flaccid muscles B. No muscle atrophy C. Hyperactive and abnormal reflexes D. Increased muscle tone
A. Flaccid muscles Lower motor neuron lesions cause flaccidity, muscle atrophy, decreased muscle tone, and loss of voluntary control.
The Family Nurse Practitioner is assessing a 55-year-old who came to the clinic complaining of being "unsteady" on their feet. What would be a test for equilibrium? A. Carlsberg test B. Walking and turning abruptly C. Heel-to-toe test D. Romberg test
D. Romberg test In the Romberg test, the client stands with feet close together and eyes closed. If the client sways and tends to fall, this is considered a positive Romberg test, indicating a problem with equilibrium. The examiner stands fairly close to the client during this test in case the client loses balance.
The nurse is completing a neurologic assessment and uses the whisper test to assess which cranial nerve? A. Acoustic B. Vagus C. Facial D. Olfactory
A. Acoustic Clinical examination of the acoustic nerve can be done by the whisper test. Having the client say "ah" tests the vagus nerve. Observing for symmetry when the client performs facial movements tests the facial nerve. The olfactory nerve is tested by having the client identify specific odors.
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: A. Sympathetic nervous system B. Parasympathetic nervous system C. Endocrine system D. Musculoskeletal system
A. Sympathetic nervous system The division of the autonomic nervous system called the sympathetic nervous system regulates the expenditure of energy. The neurotransmitters of the sympathetic nervous system are called catecholamines. During an emergency situation or an intensely stressful event, the body adjusts to deliver blood flow and oxygen to the brain, muscles, and lungs that need to react in the situation.
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? A. "I have not had anything to eat or drink since 3 hours ago." B. "I am trying to quit smoking and have a patch on." C. "i have been trying to get an appointment for so long." D. "My legs go numb sometimes when I sit too long."
B. "I am trying to quit smoking and have a patch on." Before the patient enters the room where the MRI is to be performed, all metal objects and credit cards (the magnetic field can erase them) must be removed. This includes medication patches that have a metal backing and metallic lead wires; these can cause burns if not removed
The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of cranial nerve: A. II B. VIII C. XI D. VI
B. VIII There are 12 pairs of cranial nerves. Cranial nerve VIII is the vestibulocochlear or auditory nerve responsible for hearing and balance.
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 A. Visual agnosia B. Ataxia C. Astereognosis D. A positive Romberg
C. Astereognosis Astereognosis is the inability to identify an object by touch.
A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure? A. Prone, with the head turned to the right B. Lateral, with right leg flexed C. Lateral recumbent, with thighs flexed D. Supine, with knees raised toward the chest
C. Lateral recumbent, with thighs flexed To maximize the space between the vertebrae, the client is placed in a lateral recumbent position with the thighs flexed toward the chin as much as possible. The needle is inserted between L4 and L5. The positions in the other answer choices would not allow as much space between L4 and L5.
Lesions in the temporal lobe may result in which type of agnosia? A. Visual B. Tactile C. Relationship D. Auditory
D. Auditory Lesions in the temporal lobe (lateral and superior portions) may result in auditory agnosia.
A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with: A. Visual acuity B. Thinking and reasoning C. Body temperature control D. Balance and equilibrium
C. Body temperature control The body's thermostat is located in the hypothalamus; therefore, injury to that area can cause problems with body temperature control.
Which of the following neurotransmitters are deficient in myasthenia gravis? A. Acetylcholine B. Serotonin C. Dopamine D. GABA
A. 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.
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? A. Parasympathetic B. Sympathetic C. Central D. Peripheral
A. Parasympathetic The parasympathetic division of the autonomic nervous system works to conserve body energy and is partly responsible for slowing heart rate, digesting food, and eliminating body wastes.
The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart? A. CN I B. CN III C. CN II D. CN IV
B. CN II The nurse assesses vision and thus the optic nerve (cranial nerve II) by use of a Snellen eye chart.
The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern? A. Client reports a piercing feeling B. CSF cloudy in nature C. Client reports pressure relief in the head D. Physician maintains aseptic procedure
B. CSF cloudy in nature The nurse would note cloudy cerebrospinal fluid as a concern. Cloudy fluid is an indication of infection.
Low levels of the neurotransmitter serotonin lead to which of the following disease processes? A. Parkinson's disease B. Depression C. Myasthenia gravis D. Seizures
B. Depression A decrease of serotonin leads to depression. A decrease in the amount of acetylcholine causes myasthenia gravis. Parkinson's disease is caused by a depletion of dopamine. Decreased levels of GABA may cause seizures.
Which cerebral lobe contains the auditory receptive areas? A. Occipital B. Temporal C. Parietal D. Frontal
B. Temporal The temporal lobe plays the most dominant role of any area of the cortex in cerebration. The frontal lobe, the largest lobe, controls concentration, abstract thought, information storage or memory, and motor function
To evaluate a client's cerebellar function, a nurse should ask: A. "Have you noticed any changes in your muscle strength?" B. "Do you have any difficulty speaking?" C. "Do you have any trouble swallowing foods or fluid?" D. "Do you have any problems with balance?"
C. "Do you have any problems with balance?" To evaluate cerebellar function, the nurse should ask the client about problems with balance and coordination. The nurse asks about difficulty speaking or swallowing to assess the functions of cranial nerves IX, X, and XII. Questions about muscle strength help her evaluate the client's motor system.
A nurse is completing a neurological assessment and determines that the client has significant visual deficits. A brain tumor is considered. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit? A. Temporal B. Frontal C. Occipital D. Parietal
C. Occipital The vision center is located in the occipital lobe. There is little other functioning that may interfere with the visual process in the other lobes of the brain.
Which of the following is a manifestation of an upper motor neuron lesion? A. Muscle atrophy B. Decreased reflexes C. Decreased muscle tone D. Muscle spasticity
D. Muscle spasticity Manifestations of a upper motor neuron lesion include muscle spasticity, no muscle atrophy, increased muscle tone, and hyperactive reflexes.
During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates: A. Cranial nerves VI and VIII B. Cranial nerves I and II C. Cranial nerves III and V D. Cranial nerves IX and X
D. Cranial nerves IX and X Swallowing is a motor function of cranial nerves IX and X.
A patient is scheduled for an electroencephalogram (EEG) in the morning. What food on the patient's tray should the nurse remove prior to the test? A. Orange juice B. Coffee C. Toast D. Eggs
B. Coffee Antiseizure agents, tranquilizers, stimulants, and depressants should be withheld 24 to 48 hours before an EEG, because these medications can alter the EEG wave patterns or mask the abnormal wave patterns of seizure disorders (Pagana & Pagana, 2009). Coffee, tea, chocolate, and cola drinks are omitted from the meal before the test because of their stimulating effect.
The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of cranial nerve: A. VI B. II C. VIII D. XI
C. VIII There are 12 pairs of cranial nerves. Cranial nerve VIII is the vestibulocochlear or auditory nerve responsible for hearing and balance.
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? A. "There's no other option but to assume the knee-chest position." B. "I'll report your concerns to the physician." C. "Lying on your left side will be fine during the procedure." D. "Although the required position may not be comfortable, it will make the procedure safer and easier to perform."
D. "Although the required position may not be comfortable, it will make the procedure safer and easier to perform." The nurse should explain that the knee-chest position is necessary to make the procedure safer and easier to perform. Lying on his left side won't make the procedure easy or safe to perform. The nurse shouldn't simply tell the client there is no other option because the client is entitled to understand the rationale for the required position. Reporting the client's concerns to the physician won't meet the client's needs in this situation.
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? A. Somnolence B. Comatose C. Stupor D. Normal
B. Comatose The GSC is used to measure the LOC. The scale consists of three parts: eye opening response, best verbal response, and best motor response. A normal response is 15. A score of 7 or less is considered comatose. Therefore, a score of 6 indicates the client is in a state of coma and not in any other state such as stupor or somnolence. The evaluations are recorded on a graphic sheet where connecting lines show an increase or decrease in the LOC.
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? A. Weak muscular tone B. Flaccidity C. Abnormal posture D. Decorticate posturing
B. Flaccidity The nurse would document flaccidity when the client makes no motor response to stimuli. Abnormal posturing and weak motor tone would be documented specifically as the nurse would assess. Decorticate posturing is when a client is stiff with bent arms and clenched fists with legs straight out.
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? A. "It is a test for balance." B. "It is a test for muscle strength." C. "It is a test for motor ability." D. "It is a test for coordination."
A. "It is a test for balance." The Romberg test screens for balance. The client stands with feet together and arms at the side, first with eyes open and then with both eyes closed for 20 to 30 seconds. Slight swaying is normal, but a loss of balance is abnormal and is considered a positive Romberg test.
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. A. Reduced papillary responses B. Decreased muscle mass C. Increased sensitivity to heat and cold D. Hyper-reactive deep tendon reflexes E. Increased sensitivity of taste buds F. Stage IV sleep is prolonged
A. Reduce papillary responses B. Decreased muscle mass C. Increased sensitivity to heat and cold
The nurse is assessing the client's mental status . Which question will the nurse include in the assessment? A. "Who is the president of the United States?" B. "Can you count backward from 100?" C. "Can you write your name on this piece of paper?" D. "Are you having hallucinations now?"
A. "Who is the president of the United States?" Assessing orientation to time, place, and person assists in evaluating mental status. Does the client know what day it is, what year it is, and the name of the president of the United States? Is the client aware of where he or she is? Is the client aware of who the examiner is and why he or she is in the room? "Can you write your name on this piece of paper?" will assess language ability.
Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed? A. Clonus B. Ataxia C. Rigidity D. Flaccidity
A. Clonus Clonus occurs when the foot is abruptly dorsiflexed. It continues to "beat" two or three times before it settles into a position of rest. Sustained clonus always indicates the present of central nervous system disease and requires further evaluation.
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? A. Cranial nerve XII B. Cranial nerve V C. Cranial nerve XI D. Cranial nerve I
A. Cranial nerve XII Assessment of the movement of the tongue is cranial nerve XII .
Which cranial nerve is responsible for muscles that move the eye and lids? A. Trigeminal B. Facial C. Vestibulocochlear D. Oculomotor
D. Oculomotor The oculomotor (III) cranial nerve is also responsible for pupillary constriction and lens accommodation. The trigeminal (V) cranial nerve is responsible for facial sensation, corneal reflex, and mastication. The vestibulocochlear (VII) cranial nerve is responsible for hearing and equilibrium. The facial (VII) nerve is responsible for salivation, tearing, taste, and sensation in the ear.
Cranial nerve IX is also known as which of the following? A. Glossopharyngeal B. Spinal accessory C. Vagus D. Hypoglossal
A. Glossopharyngeal Cranial nerve IX is the glossopharyngeal nerve. The vagus nerve is cranial nerve X. Cranial nerve XII is the hypoglossal nerve. The spinal accessory is the cranial nerve XI.
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? A. Heartbeat to decrease B. Blood vessels in heart to dilate C. Blood vessels in skeletal muscles to dilate D. Blood pressure to increase
A. Heartbeat to decrease 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.
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? A. Occipital B. Frontal C. Parietal D. Temporal
A. Occipital The vision center is located in the occipital lobe. There is little other functioning that may interfere with the visual process in the other lobes of the brain.
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? A. Nerve conduction studies B. Lumbar puncture C. EMG D. Echoencephalography
B. Lumbar puncture Changes in CSF occur in many neurologic disorders. A lumbar puncture (spinal tap) is performed to obtain samples of CSF from the subarachnoid space for laboratory examination and to measure CSF pressure.
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: A. Response due to interrupted impulses from the CNS B. Identification of information due to slowed passages of information to brain C. Processing information transferred from the environment D. Cognitive ability to understand relayed information
A. Response due to interrupted impulses from the CNS The central nervous system is composed of the brain and the spinal cord. Motor neurons transmit impulses from the central nervous system. Slowing transmission in this area would slow the response of transmission leading to a delay in reaction. Sensory neurons transmit impulses from the environment to the central nervous system, allowing identification of a stimulus. Cognitive centers of the brain interpret the information.
A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first? A. Maintain the client NPO for 6 hours before the test B. Obtain a blood sample to evaluate BUN and creatinine concentrations C. Assess the client for medication allergies D. Obtain two large-bore IV lines
C. Assess the client for medication allergies If a contrast agent is used, the client must be assessed before the CT scan for an iodine/shellfish allergy, because the contrast agent used may be iodine based. If the client has no allergies to shellfish, then kidney function must also be evaluated, as the contrast material is cleared through the kidneys.
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? A. Frontal lobe B. Occipital lobe C. Brain stem D. Parietal lobe
C. Brain stem The brain stem consists of the midbrain, pons, and medulla oblongata (see Fig. 65-2). Portions of the pons help regulate respiration. Motor fibers from the brain to the spinal cord and sensory fibers from the spinal cord to the brain are located in the medulla. Reflex centers for respiration, blood pressure, heart rate, coughing, vomiting, swallowing, and sneezing are located in the medulla.
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? A. Traumatic puncture B. Not ambulating soon enough C. Cerebral spinal fluid leakage at the puncture site D. Damage to the spinal cord
C. Cerebral spinal fluid leakage at the puncture site The headache is caused by cerebral spinal fluid (CSF) leakage at the puncture site. The supply of CSF in the cranium is depleted so that there is not enough to cushion and stabilize the brain. When the client assumes an upright position, tension and stretching of the venous sinuses and pain-sensitive structures occur.
If a client has a lower motor neuron lesion, the nurse would expect the client to exhibit A. Decreased muscle tone B. Hyperactive reflexes C. Muscle spasticity D. No muscle atrophy
A. Decreased muscle tone A client with a lower motor neuron lesion would be expected to have decreased muscle tone. Those with upper motor neuron lesions would have hyperactive reflexes, no muscle atrophy, and muscle spasticity.
To assess a client's cranial nerve function, a nurse should assess: A. Orientation to person, time, and place B. Gag reflex C. Arm drifting D. Hand grasp
B. Gag reflex The gag reflex is governed by the glossopharyngeal nerve, cranial nerve IX. The other choices would not be involved in a cranial nerve assessment. Hand grip and arm drifting are part of motor function assessment. Orientation is an assessment parameter related to a mental status examination.
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. Ataxic B. Helicopod C. Dystrophic D. Steppage
B. Helicopod A helicopod gait is an abnormal gait in which the client's feet make a half circle with each step.
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: A. Assessment of the client's gait B. Evaluation of bowel and bladder functions C. Evaluation of the corneal reflex D. Examination of the fundus of the eye
C. Evaluation of the corneal reflex During an acute crisis, the nurse should check the corneal reflex response to rapidly assess brain stem function. Other components of the brief initial neurologic assessment usually include level of consciousness, pupillary response, and motor response in the arms and legs. If appropriate and if time permits, the nurse also may assess sensory responses of the arms and legs. Emergency assessment doesn't include fundus examination unless the client has sustained direct eye trauma.
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? A. VII B. III C. X D. VIII
D. VIII Cranial nerve VIII (acoustic) can be checked to assess equilibrium status.
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? A. 3+ B. 2+ C. 1+ D. 0
C. 1+ Diminished or hypoactive DTRs are indicated by a score of 1+, no response by a score of 0, a normal response by a score of 2+, and an increased response by a score of 3+. Reference:
Which term refers to the inability to coordinate muscle movements, resulting difficulty walking? A. Rigidity B. Spasticity C. Ataxia D. Agnosia
C. Ataxia Ataxia is the inability to coordinate voluntary muscle action; tremors (rhythmic, involuntary movements) noted at rest or during movement suggest a problem in the anatomic areas responsible for balance and coordination.
There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected with decreased visual fields. A. Cranial nerve I B. Cranial nerve IV C. Cranial nerve II D. Cranial nerve III
C. Cranial nerve II The three sensory cranial nerves are I, II and VIII. Cranial nerve II (optic) is affected with decreased visual fields and acuity.
