prepu Ch. 65: Assessment of Neurologic Function

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

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

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

Correct response: gag reflex. Explanation: The gag reflex is governed by the glossopharyngeal nerve, one of the cranial nerves. Hand grip and arm drifting are part of motor function assessment. Orientation is an assessment parameter related to a mental status examination.

What part of the brain controls and coordinates muscle movement? Cerebellum Cerebrum Midbrain Brain stem

Correct response: Cerebellum Explanation: The cerebellum, which is located behind and below the cerebrum, controls and coordinates muscle movement.

Low levels of the neurotransmitter serotonin lead to which of the following disease processes? Myasthenia gravis Depression Seizures Parkinson's disease

Correct response: Depression Explanation: 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.

A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in thought content. emotional status. intellectual function. motor ability.

Correct response: thought content. Explanation: Hallucinations are disturbances of thought content. They are not disturbances in motor ability, intellectual function, or emotional status.

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

Correct response: Acoustic Explanation: 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 spinal cord is composed of 31 pairs of spinal nerves. How many pairs of thoracic nerves are contained within the spinal column? Eight Twelve Five One

Correct response: Twelve Explanation: There are twelve pairs of thoracic nerves, five lumbar and sacral nerves, eight cervical, and one coccygeal.

To evaluate a client's cerebellar function, a nurse should ask: "Do you have any problems with balance?" "Have you noticed any changes in your muscle strength?" "Do you have any trouble swallowing food or fluids?" "Do you have any difficulty speaking?"

Correct response: "Do you have any problems with balance?" Explanation: 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 and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following? "The blood provides moisture at the site, which encourages healing." "The blood will replace the cerebral spinal fluid that has leaked out." "The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid." "The blood can repair damage to the spinal cord that occurred with the procedure."

Correct response: "The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid." Explanation: Loss of CSF causes the headache. Occasionally, if the headache persists, the epidural blood patch technique may be used. Blood is withdrawn from the antecubital vein and injected into the site of the previous puncture. The rationale is that the blood will act as a plug to seal the hole in the dura and preven further loss of CSF. The blood is not put into the subarachnoid space. The needle is inserted below the level of the spinal cord, which prevents damage to the cord. It is not a lack of moisture that prevents healing; it is more related to the size of the needle used for the puncture.

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 physician is careful not to insert the needle far enough to reach the cord." "Damage to the spinal cord is a possibility." "The needle is not long enough to damage the cord." "The spinal cord ends at L1, so puncturing it is not possible."

Correct response: "The spinal cord ends at L1, so puncturing it is not possible." Explanation: 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 cerebral circulation receives approximately what percentage of the cardiac output? 10% 15% 25% 20%

Correct response: 15% Explanation: The cerebral circulation receives approximately 15% of the cardiac output, or 750 mL per minute.

A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first? Obtain a blood sample to evaluate BUN and creatinine concentrations. Obtain two large-bore IV lines. Assess the client for medication allergies. Maintain the client NPO for 6 hours before the test.

Correct response: Assess the client for medication allergies. Explanation: 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 suitable IV line for contrast injection and a period of fasting (usually 4 hours) are required before the study. Clients who receive an IV contrast agent are monitored during and after the procedure for allergic reactions and changes in kidney function.

Which term refers to the inability to coordinate muscle movements, resulting difficulty walking? Spasticity Rigidity Agnosia Ataxia

Correct response: Ataxia Explanation: 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. Agnosia is the loss of ability to recognize objects through a particular sensory system. Spasticity is the sustained increase in tension of a muscle when it is passively lengthened or stretched.

Lesions in the temporal lobe may result in which type of agnosia? Visual Tactile Auditory Relationship

Correct response: Auditory Explanation: Lesions in the temporal lobe (lateral and superior portions) may result in auditory agnosia. Lesions in the occipital lobe may result in visual agnosia. Lesions in the parietal lobe may result in tactile agnosia. Lesions in the parietal lobe (posteroinferior regions) may result in relationship and body part agnosia.

The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve? CN II CN IV CN III CN I

Correct response: CN I Explanation: 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.

A patient recently noted difficulty maintaining his balance and controlling fine movements. The nurse explains that the provider will order diagnostic studies for the part of his brain known as the: Cerebellum. Pons. Midbrain. Medulla oblongata.

Correct response: Cerebellum. Explanation: The cerebellum is largely responsible for coordination of all movement. It also controls fine movement, balance, position (postural) sense or proprioception (awareness of where each part of the body is), and integration of sensory input.

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? Echoencephalography Electroencephalogram Cerebral angiography Myelogram

Correct response: Cerebral angiography Explanation: The nurse would anticipate a cerebral angiography, which detects distortion of the cerebral arteries and veins . A myelogram detects abnormalities of the spinal canal. An electroencephalogram records electrical impulses of the brain. An echoencephalography is an ultrasound of the structures of the brain.

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 headches are caused by which of the following? Damage to the spinal cord Cerebral spinal fluid leakage at the puncture site Not ambulating soon enough after the procedure Traumatic puncture

Correct response: Cerebral spinal fluid leakage at the puncture site Explanation: 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.

Which is a sympathetic effect of the nervous system? Decreased respiratory rate Increased peristalsis Dilated pupils Decreased blood pressure

Correct response: Dilated pupils Explanation: Dilated pupils are a sympathetic effect of the nervous system, whereas constricted pupils are a parasympathetic effect. Decreased blood pressure is a parasympathetic effect, whereas increased blood pressure is a sympathetic effect. Increased peristalsis is a parasympathetic effect, but decreased peristalsis is a sympathetic effect. Decreased respiratory rate is a parasympathetic effect, and increased respiratory rate is a sympathetic effect.

A patient is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the patient has? Dysfunction of the spinal accessory nerve Dysfunction of the facial nerve Dysfunction of the acoustic nerve Dysfunction of the vagus nerve

Correct response: Dysfunction of the vagus nerve Explanation: The vagus nerve (cranial nerve X) controls the gag reflex and is tested by depressing the posterior tongue with a tongue blade. An absent gag reflex is a significant finding, indicating dysfunction of this nerve.

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

Correct response: Ensure that no client care equipment containing metal enters the room where the MRI table is located. Explanation: For client safety the nurse must make sure that no client care equipment that contains metal or metal parts (eg, portable oxygen tanks) enters the room where the MRI is located. The client must be assessed for the presence of medication patches with foil backing (e.g., nicotine patch) that may cause a burn. The magnetic field generated by the unit is so strong that any metal-containing items will be strongly attracted and can literally be pulled away with such great force that they can fly like projectiles toward the magnet.

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? Decorticate posturing Abnormal posture Flaccidity Weak muscular tone

Correct response: Flaccidity Explanation: 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.

Which cerebral lobes is the largest and controls abstract thought? Occipital Frontal Temporal Parietal

Correct response: Frontal Explanation: The frontal lobe also controls information storage or memory and motor function. The temporal lobe contains the auditory receptive area. The parietal lobe contains the primary sensory cortex, which analyzes sensory information and relays interpretation to the thalamus and other cortical areas. The occipital lobe is responsible for visual interpretation.

Which lobe of the brain is responsible for concentration and abstract thought? Temporal Occipital Frontal Parietal

Correct response: Frontal Explanation: The major functions of the frontal lobe are concentration, abstract thought, information storage or memory, and motor function. The parietal lobe analyzes sensory information such as pressure, vibration, pain, and temperature. The occipital lobe is the primary visual cortex. The temporal lobe contains the auditory receptive areas located around the temples.

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

Correct response: Heartbeat to decrease Explanation: 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 of the following areas of the brain are responsible for temperature regulation? Medulla Hypothalamus Thalamus Pons

Correct response: Hypothalamus Explanation: The hypothalamus also controls and regulates the autonomic nervous system and maintains temperature by promoting vasoconstriction or vasodilation. The thalamus acts primarily as a relay station for all sensation except smell. The medulla and pons are essential for respiratory function.

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

Correct response: Moving the head and chin toward the chest Explanation: 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.

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? Temporal Parietal Occipital Frontal

Correct response: Occipital Explanation: 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.

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? Parasympathetic Peripheral Central Sympathetic

Correct response: Parasympathetic Explanation: 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.

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

Correct response: Parkinson's disease Explanation: Disorders due to lesions of the basal ganglia include Parkinson's disease, Huntington's disease, and spasmodic torticollis.

Which neurotransmitter demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways? Enkephalin Norepinephrine Acetylcholine Serotonin

Correct response: Serotonin Explanation: The brain stem, hypothalamus, and dorsal horn of the spinal cord are sources of serotonin. Enkephalin is excitatory and associated with pleasurable sensations. Norepinephrine is usually excitatory and affects mood and overall activity. Acetylcholine is usually excitatory, but the parasympathetic effects are sometimes inhibitory.

A patient has been diagnosed with damage to Broca's area of the left frontal lobe. To document the extent of damage, the nurse would assess the patient's: Balance. Hearing. Speech. Vision.

Correct response: Speech. Explanation: The motor strip, which lies in the frontal lobe, anterior to the central sulcus, is responsible for muscle movement. It also contains Broca's area (left frontal lobe region in most people), critical for motor control of speech.

Which cerebral lobe contains the auditory receptive areas? Temporal Parietal Frontal Occipital

Correct response: Temporal Explanation: 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. The parietal lobe contains the primary sensory cortex, which analyzes sensory information and relays interpretation to the thalamus and other cortical areas. The occipital lobe is responsible for visual interpretation.

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: XI VIII II VI

Correct response: VIII Explanation: There are 12 pairs of cranial nerves. Cranial nerve VIII is the vestibulocochlear or auditory nerve responsible for hearing and balance. Cranial nerve II is the optic nerve. Cranial nerve VI is the abducens nerve responsible for eye movement. Cranial nerve XI is the accessory nerve and is involved with head and shoulder movement.

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? electroencephalogram cerebral angiography echoencephalography milligram

Correct response: cerebral angiography Explanation: The nurse would anticipate a cerebral angiography, which detects distortion of the cerebral arteries and veins . A milligram detects abnormalities of the spinal canal. An electroencephalogram records electrical impulses of the brain. An echoencephalography is an ultrasound of the structures of the brain.

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

Correct response: close his or her eyes and stand erect. Explanation: In the Romberg test, the client stands erect with the feet close together and eyes closed. If the client sways as if to fall, it is considered a positive Romberg test. All of the other options include components of neurologic tests, indicating neurologic deficits and balance.

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: convert glycogen to glucose for immediate use. maintain a basal rate of functioning. produce a toxic byproduct in relation to stress. cease function and shunt blood to the heart and lungs.

Correct response: convert glycogen to glucose for immediate use. Explanation: 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.

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: cranial nerves I and II. cranial nerves III and V. cranial nerves VI and VIII. cranial nerves IX and X.

Correct response: cranial nerves IX and X. Explanation: Swallowing is a motor function of cranial nerves IX and X. Cranial nerves I, II, and VIII don't possess motor functions. The motor functions of cranial nerve III include extraocular eye movement, eyelid elevation, and pupil constriction. The motor function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement.

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

Correct response: refrain from eating or drinking for now. Explanation: 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 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: processing information transferred from the environment. cognitive ability to understand relayed information. response due to interrupted impulses from the central nervous system identification of information due to slowed passages of information to brain.

Correct response: response due to interrupted impulses from the central nervous system Explanation: 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.