PrepU Final Nurs 242
Which of the following neurotransmitters are deficient in myasthenia gravis? -Acetylcholine -GABA -Serotonin -Dopamine
Acetylcholine Explanation: 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 nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart? -CN I -CN III -CN IV -CN II
CN II Explanation: The nurse assesses vision and thus the optic nerve (cranial nerve II) by use of a Snellen eye chart.
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: -Midbrain. -Cerebellum. -Pons. -Medulla oblongata.
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.
Which structural and motor change is related to aging and may be assessed in geriatric clients during an examination of neurological function? -Increased autonomic nervous system responses -Enhanced reaction and movement times -Decreased or absent deep tendon reflexes -Increased pupillary responses
Decreased or absent deep tendon reflexes Explanation: Structural and motor changes related to aging that may be assessed in geriatric clients include decreased or absent deep tendon reflexes. Pupillary responses are reduced or may not appear at all in the presence of cataracts. There is an overall slowing of autonomic nervous system responses with aging. Strength and agility are diminished and reaction and movement times are decreased.
Which of the following is an age-related change in the nervous system? -Increased cerebral blood flow -Loss of neurons in the brain -Increased myelin -More efficient temperature regulation
Loss of neurons in the brain Explanation: Structural changes include loss of neurons in the brain, reduced cerebral blood flow, less efficient temperature regulation, and decreased myelin, resulting in decreased nerve conduction in some nerves.
A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following? -Clopidogrel -Tissue plasminogen activator (tPA) -Atorvastatin -Extended release dipyridamole
Tissue plasminogen activator (tPA) Explanation: In 1996, the FDA approved the use of tissue plasminogen activator (tPA) for the treatment of acute ischemic stroke within the first 3 hours of symptom onset.
The spinal cord is composed of 31 pairs of spinal nerves. How many pairs of thoracic nerves are contained within the spinal column? -Eight -One -Twelve -Five
Twelve Explanation: There are twelve pairs of thoracic nerves, five lumbar and sacral nerves, eight cervical, and one coccygeal.
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
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 assisting with a community screening for people at high risk for stroke. To which of the following clients would the nurse pay most attention? -A 40-year-old White woman -A 28-year-old pregnant Black woman -A 60-year-old Black man -A 62-year-old White woman
A 60-year-old Black man Explanation: The 60-year-old Black man has three risk factors: gender, age, and race. Black people have almost twice the incidence of first stroke compared with White people.
The nurse is caring for a client who exhibits abnormal results of the Weber test and Rinne test. The nurse should suspect dysfunction involving what cranial nerve? -Trigeminal -Hypoglossal -Trochlear -Acoustic
Acoustic Explanation: Abnormal hearing can correlate with damage to cranial nerve VIII (acoustic). The acoustic nerve functions in hearing and equilibrium. The trigeminal nerve functions in facial sensation, corneal reflex, and chewing. The hypoglossal nerve moves the tongue. The trochlear nerve controls muscles that move the eye.
The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern? -Cerebrospinal fluid is cloudy in nature. -Physician maintains aseptic procedure. -Client reports pressure relief in the head. -Client reports a piercing feeling.
Cerebrospinal fluid is cloudy in nature. Explanation: The nurse would note cloudy cerebrospinal fluid as a concern. Cloudy fluid is an indication of infection. The physician is correct to maintain aseptic procedure. A piercing feeling and pressure relief are common during and after the procedure.
Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed? -Clonus -Rigidity -Flaccidity -Ataxia
Clonus Explanation: 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. Ataxia is incoordination of voluntary muscle action. Rigidity is an increase in muscle tone at rest characterized by increased resistance to passive movement. Flaccid posturing is usually the result of lower brain stem dysfunction; the client has no motor function, is limp, and lacks motor tone.
Which is a sympathetic effect of the nervous system? -Increased peristalsis -Decreased respiratory rate -Dilated pupils -Decreased blood pressure
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 has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? -Absence seizure -Generalized seizure -Focal seizure -Unclassified seizure
Generalized seizure Explanation: Generalized seizures often involve both hemispheres of the brain, causing both sides of the body to react. Intense rigidity of the entire body may occur, followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction). This pattern of rigidity does not occur in patients who experience unclassified, absence, or focal seizures.
You are taking care of a client who is taking an anticonvulsant. Why should you advise the client not to stop taking the drug abruptly? -It may cause loss in appetite. -It may cause alopecia. -It may trigger status epilepticus. -It may cause severe and ugly skin rashes.
It may trigger status epilepticus. Explanation: Abrupt withdrawal of any anticonvulsant may cause status epilepticus or continuous seizure activity. Therefore, the drug should be withdrawn gradually and not abruptly. Abrupt withdrawal of any anticonvulsant does not cause loss of appetite, alopecia, or rashes.
The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer? -Urea -Mannitol -Isosorbide -Glycerin
Mannitol Explanation: If signs and symptoms of increased ICP occur, efforts to decrease the ICP are initiated: alignment of the head in a neutral position without flexion to promote venous drainage, elevation of the head of the bed to 30 degrees (when prescribed), administration of mannitol (an osmotic diuretic), and possible administration of pharmacologic paralyzing agents.
Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle including -a low-fat, low-cholesterol diet and increased exercise. -eating fish no more than once a month. -a high-protein diet and increased weight-bearing exercise. -a low-cholesterol, low-protein diet and decreased aerobic exercise.
a low-fat, low-cholesterol diet and increased exercise. Explanation: Health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle including a low-fat, low-cholesterol diet and increased exercise. Recent evidence suggests that eating fish two or more times per week reduces the risk of thrombotic stroke for women.
Which activities would the client with a T4 spinal cord injury be able to perform independently? Select all that apply. -Writing -Breathing -Eating -Transferring to a wheelchair -Ambulating
Eating Breathing Transferring to a wheelchair Writing Explanation: Eating, breathing, transferring to a wheelchair, and writing are functional abilities for those with a T4 injury. Ambulation can be performed independently by a client with an injury at T11-S5 injury.
A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement? -"I sense that you are happy it was not a stroke". -"TIA symptoms are short-lived and resolve within 24 hours". -"TIA is a warning sign. Let's talk about lowering your risks." -"People who experience a TIA will develop a stroke".
"TIA is a warning sign. Let's talk about lowering your risks." Explanation: TIA is a warning sign and can be used to empower clients to make life changes to lower the risks. Sensing the client is happy is a psychotherapeutic response but does not lead to teaching and learning for health promotion. TIAs can lead to a stroke for approximately one third of the clients but is not a definitive result and presents as a frightening statement without empowering change. TIA symptoms are short-lived, but this is a factual statement that does not provide additional information to the client.
A client has been admitted for observation after a closed head injury. There is clear fluid leaking from the client's nose. How would the nurse assess if this drainage is CSF? -Assess for crepitus around the nose -Assess for a halo sign -Assess for bloody drainage -Assess for a wing sign
Assess for a halo sign Explanation: Most clients are hospitalized for at least 24 hours after a significant head injury. The nurse examines the client to identify signs of head trauma and tests drainage from the nose or ear. To detect any CSF drainage, the nurse looks for a halo sign, which is a blood stain surrounded by a clear or yellowish stain. If drainage is present, the nurse allows it to flow freely onto porous gauze and avoids tightly plugging the orifice.
A client in the emergency department has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the client has which type of skull fracture? -Simple -Comminuted -Linear -Basilar
Basilar Explanation: An area of ecchymosis (bruising) may be seen over the mastoid (Battle sign) in a basilar skull fracture. Basilar skull fractures are also suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea). A simple (linear) fracture is a break in bone continuity. A comminuted fracture refers to a splintered or multiple fracture line.
A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform? -Administer an analgesic. -Call the physician immediately. -Sit with the client for a few minutes. -Inform the nurse manager.
Call the physician immediately. Explanation: The nurse should notify the physician immediately because the headache may be an indication that the aneurysm is leaking. Sitting with the client is appropriate but only after the physician has been notified of the change in the client's condition. The physician will decide whether or not administration of an analgesic is indicated. Informing the nurse manager isn't necessary.
The nurse is planning the care of a client with Parkinson disease. The nurse should be aware that treatment will focus on what pathophysiologic phenomenon? -Premature degradation of acetylcholine -Insufficient synthesis of epinephrine -Decreased availability of dopamine -Delayed reuptake of serotonin
Decreased availability of dopamine Explanation: Parkinson disease develops from decreased availability of dopamine, not acetylcholine, epinephrine, or serotonin.
Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply. -Verbal response -Muscle strength -Eye opening -Intelligence -Motor response
Eye opening Verbal response Motor response Explanation: LOC can be assessed based on the criteria in the GCS, which include eye opening, verbal response, and motor response. The patient's responses are rated on a scale from 3 to 15. Intelligence and muscle strength are not measured in the GCS.
A client has sustained a head injury to the occipital area. He cannot identify a familiar object by looking at it. The nurse knows that this deficit is which of the following? -Visual agnosia -Ataxia -Positive Romberg -Astereognosis
Visual agnosia Explanation: Visual agnosia is the loss of ability to recognize objects when seeing them. The Romberg test has to do with balance. Ataxia is defined as incoordination of voluntary muscle action. Astereognosis is the inability to identify an object by touch.
Which lobe of the brain is responsible for concentration and abstract thought? -Parietal -Temporal -Occipital -Frontal
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.
A critical care nurse is caring for a client with a cerebrovascular accident (CVA) The client is prescribed heparin for treatment. The nurse knows to monitor the client for what adverse effects? -Respiratory distress -Hemorrhage -High blood pressure -Migraine attacks
Hemorrhage Explanation: A client with a CVA who is given heparin should be monitored for hemorrhage and bleeding at the subcutaneous injection site. Respiratory distress, high blood pressure, or migraine attacks are not likely to occur in such a client.
The nurse is caring for a client with an inoperable brain tumor. What is a major threat to this client? -Hypovolemia -Increased intracranial pressure -Decreased intracranial pressure -Hypervolemia
Increased intracranial pressure Explanation: Nursing management depends on the area of the brain affected, tumor type, treatment approach, and the client's signs and symptoms. If the tumor is inoperable or has expanded despite treatment, increased intracranial pressure (ICP) is a major threat. In this scenario, there are no indications that volume either increased of decreased is an issue.
A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this patient's care, the nurse would expect to administer what priority medication? -Mannitol (Osmitrol) -Spirolactone (Aldactone) -Hydrochlorothiazide (HydroDIURIL) -Furosemide (Lasix)
Mannitol (Osmitrol) Explanation: The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce cerebral edema. This drug acts by reducing the volume of brain and extracellular fluid. Spirolactone, furosemide, and hydrochlorothiazide are diuretics that are not typically used in the treatment of increased ICP resulting from cerebral edema.
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 -Sympathetic -Central
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.
A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-related changes that may influence the assessment results. Of what phenomenon should the nurse be aware? -Hyperactive deep tendon reflexes -Reduction in cerebral blood flow -Hypersensitivity to painful stimuli -Increased cerebral metabolism
Reduction in cerebral blood flow Explanation: Reduction in cerebral blood flow (CBF) is a change that occurs in the normal aging process. Deep tendon reflexes can be decreased or, in some cases, absent. Cerebral metabolism decreases as the client advances in age. Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used.
Which neurotransmitter demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways? -Acetylcholine -Norepinephrine -Serotonin -Enkephalin
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 diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? -To determine the cause of the TIA -To prevent seizure activity that is common following a TIA -To decrease cerebral edema -To prevent a stroke by removing atherosclerotic plaques blocking cerebral flow
To prevent a stroke by removing atherosclerotic plaques blocking cerebral flow Explanation: The main surgical procedure for select patients with TIAs is carotid endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extra cranial arteries. An endarterectomy does not decrease cerebral edema, prevent seizure activity, or determine the cause of a TIA.
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 IX and X. -cranial nerves VI and VIII. -cranial nerves I and II. -cranial nerves III and V.
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.
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? -III -VI -IV -V
V Explanation: 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.
A trauma client in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death? -Electromyography (EMG) -Magnetic resonance imaging (MRI) -Electroencephalography (EEG) -Computed tomography (CT)
Electroencephalography (EEG) Explanation: The EEG can be used in determining brain death. MRI, CT, and EMG are not normally used in determining brain death.
The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform? -Assess the player's reflexes. -Ensure that the player is not moved. -Perform a rapid assessment of the player's range of motion. -Obtain the player's vital signs, if possible.
Ensure that the player is not moved. Explanation: At the scene of the injury, the client must be immobilized on a spinal (back) board, with the head and neck maintained in a neutral position, to prevent an incomplete injury from becoming complete. This is a priority over determining the client's vital signs. It would be inappropriate to test ROM or reflexes.
Which is the most common cause of spinal cord injury (SCI)? -Acts of violence -Motor vehicle crashes -Sports-related injuries -Falls
Motor vehicle crashes Explanation: The most common cause of SCI is motor vehicles crashes, which account for 35% of the injuries. Falls, sports-related injuries, and acts of violence are also potential causes of SCI, but are not most common.
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 vagus nerve -Dysfunction of the acoustic nerve -Dysfunction of the facial nerve -Dysfunction of the spinal accessory nerve
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.
A patient suffering a stroke is having a difficult time swallowing. What would the nurse document this finding as? -Ataxia -Dysphagia -Arthralgia -Dysarthria
Dysphagia Explanation: Stroke can result in dysphagia (difficulty swallowing) due to impaired function of the mouth, tongue, palate, larynx, pharynx, or upper esophagus. Patients must be observed for paroxysms of coughing, food dribbling out of or pooling in one side of the mouth, food retained for long periods in the mouth, or nasal regurgitation when swallowing liquids. Swallowing difficulties place the patient at risk for aspiration, pneumonia, dehydration, and malnutrition.
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 IV -CN I -CN III -CN II
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.
Which term refers to a method of recording, in graphic form, the electrical activity of a muscle? -Electrocardiography -Electrogastrography -Electromyography -Electroencephalography
Electromyography Explanation: 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.
Which cerebral lobes is the largest and controls abstract thought? -Parietal -Occipital -Frontal -Temporal
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.
A 22-year-old man is being closely monitored in the neurological ICU after suffering a basal skull fracture during an assault. The nurse's hourly assessment reveals the presence of a new blood stain on the patient's pillow that is surrounded by a stain that is pale yellow in color. The nurse should follow up this finding promptly because it is suggestive of: -Leakage of cerebrospinal fluid (CSF) -An epidural hematoma -Increasing intracranial pressure (ICP) -Meningitis
Leakage of cerebrospinal fluid (CSF) Explanation: In patients with a skull fracture, a halo sign (a blood stain surrounded by a yellowish stain) may be seen on bed linens or on the head dressing and is highly suggestive of a CSF leak. This finding is not specifically indicative of meningitis, increased ICP or an epidural hematoma.
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? -Not ambulating soon enough after the procedure -Damage to the spinal cord -Traumatic puncture -Cerebral spinal fluid leakage at the puncture site
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.
A nurse is providing education to a community group about ischemic strokes. One group member asks if there are ways to reduce the risk for stroke. Which of the following is a risk factor that can be modified? -Advanced age -African heritage -Hypertension -Male gender
Hypertension Explanation: Modifiable risk factors for ischemic stroke include hypertension, atrial fibrillation, hyperlipidemia, diabetes mellitus, smoking, asymptomatic carotid stenosis, obesity, and excessive alcohol consumption. Non-modifiable risk factors include advanced age, gender, and race.
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. -Speech. -Hearing. -Vision.
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.
The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply. -Pupil reacts to light -Pupil reaction quick -Pinpoint pupils -Absence of pupillary response -Unequal pupils
Unequal pupils Pinpoint pupils Absence of pupillary response Explanation: Normal assessment findings includes that the pupils are equal and reactive to light. Pupils that are unequal, pinpoint in nature, or fail to respond indicate a neurologic impairment.
A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with: -body temperature control. -balance and equilibrium. -visual acuity. -thinking and reasoning.
body temperature control. Explanation: The body's thermostat is located in the hypothalamus; therefore, injury to that area can cause problems with body temperature control. Balance and equilibrium problems are related to cerebellar damage. Visual acuity problems would occur following occipital or optic nerve injury. Thinking and reasoning problems are the result of injury to the cerebrum.
A nurse is preparing a client for a computed tomography (CT) scan that requires infusion of radiopaque dye. Which question is the most important for the nurse to ask? -"When did you last take any medication?" -"When did you last have something to eat or drink?" -"How much do you weigh?" -"Are you allergic to seafood or iodine?"
"Are you allergic to seafood or iodine?" Explanation: Seafood and the radiopaque dye used in CT contain iodine. To prevent an allergic reaction to the radiopaque dye, the nurse should ask the client about allergies to seafood or iodine before the CT scan. Because fasting is unnecessary before a CT scan, the nurse doesn't need to obtain information about the client's last food and fluid intake. The client's last dose of medication and current weight also are irrelevant.
The nurse is assessing the client's mental status . Which question will the nurse include in the assessment? -"Can you write your name on this piece of paper?" -"Are you having hallucinations now?" -"Can you count backward from 100?" -"Who is the president of the United States?"
"Who is the president of the United States?" Explanation: 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. "Can you count backward from 100?" assesses the client's intellectual function. "Are you having hallucinations?" assesses the client's thought content.
Thrombolytic therapy for the treatment of an ischemic stroke should be initiated within how many hours of the onset of symptoms to obtain the best functional outcome? -3 hours -6 hours -9 hours -12 hours
3 hours Explanation: Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in clients with ischemic stroke lead to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months. Some scientific statements have endorsed its expanded use for up to 4.5 hours.
The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? -Alteration in level of consciousness (LOC) -Tonic-clonic seizures -Generalized pain -Shortness of breath
Alteration in level of consciousness (LOC) Explanation: Alteration in LOC is the earliest sign of deterioration in a client after a hemorrhagic stroke, such as mild drowsiness, slight slurring of speech, and sluggish papillary reaction. Sudden headache may occur, but generalized pain is less common. Seizures and shortness of breath are not identified as early signs of hemorrhagic stroke.
A white female client is admitted to an acute care facility with a diagnosis of stroke. Her history reveals bronchial asthma, exogenous obesity, and iron-deficiency anemia. Which history finding is a risk factor for stroke? -Having bronchial asthma -Being white -Being obese -Being female
Being obese Explanation: Obesity is a risk factor for stroke. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, hormonal contraceptive use, emotional stress, family history of stroke, and advancing age. The client's race, gender, and bronchial asthma aren't risk factors for stroke.
Which medication classification is used preoperatively to decrease the risk of postoperative seizures? -Anticonvulsants -Diuretics -Corticosteroids -Antianxiety
Brain CT scan or MRI Explanation: CT scan or MRI differentiates CVA from other disorders and can differentiate between ischemic or hemorrhagic strokes. PT level would be done if the client is receiving anticoagulant therapy. Chest x-ray may be performed if respiratory concerns are indicated. Lumbar puncture would be done if subarachnoid bleeding is suspected.
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)? -Every 45 minutes -Every 15 minutes -Every 30 minutes -Every hour
Every 15 minutes Explanation: Neurological assessment and vital signs (except temperature) should be taken every 15 minutes initially while the patient is receiving tPA infusion.
A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take? -Face the client and establish eye contact. -Keep the television on while she speaks. -Use one long sentence to say everything that needs to be said. -Talk in a louder than normal voice.
Face the client and establish eye contact. Explanation: When speaking with a client who has aphasia, the nurse should face the client and establish eye contact. The nurse should use short phrases, not one long sentence, and give the client time between phrases to understand what is being said. Keeping extraneous and background noise such as the television to a minimum helps the client concentrate on what is being said. It isn't necessary to speak in a louder or softer voice than normal.
Which of the following areas of the brain are responsible for temperature regulation? -Thalamus -Pons -Medulla -Hypothalamus
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.
A client in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is which of the following? -Hypothalamus -Midbrain -Cerebellum -Thalamus
Hypothalamus Explanation: The hypothalamus plays an important role in the endocrine system because it regulates the pituitary secretion of hormones that influence metabolism, reproduction, stress response, and urine production. It works with the pituitary to maintain fluid balance through hormonal release and maintains temperature regulation by promoting vasoconstriction or vasodilatation. The cerebellum, thalamus, and midbrain are not directly involved in temperature regulation.
A nurse is caring for an older client who has had a hemorrhagic stroke. The client has exhibited impulsive behavior and, despite reminders from the nurse, doesn't recognize his limitations. Which priority measure should the nurse implement to prevent injury? -Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed. -Encourage the family to reprimand the client if he doesn't ask for help with transfers and mobility. -Ask a physician to order a vest and wrist restraints. -Encourage the client to do as much as possible without assistance, and to use the call light only in emergencies.
Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed. Explanation: The bed alarm will alert staff that the client is attempting to transfer, so they can come to assist. The nurse shouldn't encourage the family to reprimand the client. Instead, the nurse should ask the family to encourage the client to request assistance. The nurse should encourage the client to use the call light in all situations, not just emergencies. A vest and wrist restraints aren't appropriate unless less-restrictive measures have failed and the client is a danger to himself or others.
The Family Nurse Practitioner 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? -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 toward both sides
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.
Which cranial nerve is responsible for muscles that move the eye and lids? -Facial -Trigeminal -Vestibulocochlear -Oculomotor
Oculomotor Explanation: 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 (VIII) cranial nerve is responsible for hearing and equilibrium. The facial (VII) nerve is responsible for salivation, tearing, taste, and sensation in the ear.
In reviewing a client's history and physical examination, a nurse finds that the client was found positive for ataxia during the physician's neurological testing. Which nursing diagnosis will be a priority for this client? -Autonomic dysreflexia -Deficient fluid volume -Risk for infection -Risk for falls
Risk for falls Explanation: Ataxia means incoordination of voluntary muscle action, particularly involving those muscles used in walking. This client will be at risk for falls. There is no indication that this client has a risk for infection, low fluid volume, or autonomic dysreflexia.
A client who has sustained a head injury to the parietal lobe cannot identify a familiar object by touch. The nurse knows that this deficit is which of the following? -Positive Romberg -Ataxia -Tactile agnosia -Visual agnosia
Tactile agnosia Explanation: Tactile agnosia is the inability to identify a familiar object by touch. Visual agnosia is the loss of ability to recognize objects through sight. The Romberg test has to do with balance. Ataxia is defined as incoordination of voluntary muscle action.
A client is scheduled for standard EEG testing to evaluate a possible seizure disorder. Which nursing intervention should the nurse perform before the procedure? -Instruct the client that a standard EEG takes 2 hours -Withhold anticonvulsant medications for 24 to 48 hours before the exam -Maintain NPO status for 6 hours before the procedure -Sedate the client before the procedure, per orders
Withhold anticonvulsant medications for 24 to 48 hours before the exam Explanation: Anticonvulsant agents, tranquilizers, stimulants, and depressants should be withheld 24 to 48 hours before an EEG because these medications can alter EEG wave patterns or mask the abnormal wave patterns of seizure disorders. To increase the chances of recording seizure activity, it is sometimes recommended that the client be deprived of sleep on the night before the EEG. Coffee, tea, chocolate, and cola drinks are omitted in the meal before the test because of their stimulating effect. However, meals are not omitted, because an altered blood glucose concentration can cause changes in brain wave patterns. The client is informed that a standard EEG takes 45 to 60 minutes; a sleep EEG requires 12 hours.
A physician orders aspirin, 325 mg P.O. daily for a client who has experienced a transient ischemic attack (TIA). The nurse should teach the client that the physician has ordered this medication to: -reduce the chance of blood clot formation. -control headache pain. -enhance the immune response. -prevent intracranial bleeding.
reduce the chance of blood clot formation. Explanation: TIAs are considered forerunners of stroke. Because strokes may result from clots in cerebral vessels, physicians order aspirin to prevent clot formation by reducing platelet agglutination. A 325-mg dose of aspirin is inadequate to relieve headache pain in an adult. Aspirin doesn't affect the body's immune response. Intracranial bleeding isn't associated with TIAs, and aspirin probably would worsen any existing bleeding.
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 can repair damage to the spinal cord that occurred with the procedure." -"The blood provides moisture at the site, which encourages healing." -"The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid." -"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." 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 prevent 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 client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment? -Brain CT scan or MRI -Lumbar puncture -Chest x-ray -Prothrombin level
Anticonvulsants Explanation: Anticonvulsants are used to decrease the risk of postoperative seizures following cranial surgery. Diuretics, corticosteroids, and antianxiety medications may be used for the client with increased intracranial pressure.
The nurse is performing a neurologic assessment of a client whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the client's level of consciousness (LOC)? -Assess the client's vital signs and correlate these with the client's baselines. -Assess the client's eye opening and response to stimuli. -Document that the client currently lacks a level of consciousness. -Facilitate diagnostic testing in an effort to obtain objective data.
Assess the client's eye opening and response to stimuli. Explanation: If the client is not alert or able to follow commands, the examiner observes for eye opening; verbal response and motor response to stimuli, if any; and the type of stimuli needed to obtain a response. Vital signs and diagnostic testing are appropriate, but neither will allow the nurse to gauge the client's LOC. Inability to follow commands does not necessarily denote an absolute lack of consciousness.
A client is diagnosed with a brain tumor. As the nurse assists the client from the bed to a chair, the client begins having a generalized seizure. Which action should the nurse take first? -Put a padded tongue blade into the client's mouth and restrain his extremities. -Initiate the code team response. -Record the type of seizure and the time that it occurred. -Assist the client to the floor, in a side-lying position, and protect him with linens.
Assist the client to the floor, in a side-lying position, and protect him with linens. Explanation: The nurse should protect the client from injury by assisting him to the floor, in a side-lying position, and protect him from harm by padding the floor with bed linens. Initiating a response from the code team isn't necessary because seizures are self-limiting. As long as the client's airway is protected, his cardiopulmonary status isn't affected. The nurse shouldn't force anything into the client's mouth during a seizure; doing so may cause injury. Documenting seizure activity is important, but it doesn't take priority over client safety.
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? -Parietal lobe -Frontal lobe -Brain stem -Occipital lobe
Brain stem Explanation: 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.
Which disturbance results in loss of half of the visual field? -Homonymous hemianopsia -Nystagmus -Anisocoria -Diplopia
Homonymous hemianopsia Explanation: Homonymous hemianopsia (loss of half of the visual field) may occur from stroke and may be temporary or permanent. Double vision is documented as diplopia. Nystagmus is ocular bobbing and may be seen in multiple sclerosis. Anisocoria is unequal pupils.
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? -Positive Romberg test, indicating a problem with equilibrium -Negative Romberg test, indicating a problem with body mass -Negative Romberg test, indicating a problem with vision -Positive Romberg test, indicating a problem with level of consciousness
Positive Romberg test, indicating a problem with equilibrium Explanation: If the client sways and starts to fall during the Romberg test, it indicates a positive result. This means the client has a problem with equilibrium. The examiner or the nurse stands fairly close to the client during the test to prevent the client from falling. The Romberg test is used to assess the client's motor function, including muscle movement, size, tone, strength, and coordination. However, the Romberg test is not used to assess the client's level of consciousness, body mass, or vision.
A nurse is evaluating a client's cranial nerves during a routine examination. To assess the function of cranial nerve XII (hypoglossal), the nurse should assess the client's ability to: -stick out the tongue and move it rapidly from side to side and in and out. -read an eye chart from a distance of 20?. -smell and identify a nonirritating, aromatic odor. -elevate the shoulders, both with and without resistance.
stick out the tongue and move it rapidly from side to side and in and out. Explanation: To test cranial nerve XII, which controls tongue movement, the nurse should instruct the client to stick out the tongue and move it rapidly from side to side and in and out. The nurse would ask the client to smell and identify a nonirritating, aromatic odor when testing the function of cranial nerve I, the olfactory cranial nerve. Asking the client to read an eye chart is part of assessing cranial nerve II, the optic cranial nerve. Having the client elevate the shoulders with and without resistance is part of assessing cranial nerve XI, the spinal accessory cranial nerve that innervates the sternocleidomastoid muscle and the upper portion of the trapezius muscle.
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: -musculoskeletal system. -endocrine system. -sympathetic nervous system. -parasympathetic nervous system.
sympathetic nervous system. Explanation: 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. The musculoskeletal system benefits from the sympathetic nervous system as the fight-or-flight effects pump blood to the muscles. The parasympathetic nervous system works to conserve body energy not expend it during an emergency. The endocrine system regulates metabolic processes.
The nurse is assisting with a lumbar puncture and observes that when the physician obtains CSF, it is clear and colorless. What does this finding indicate? -A subarachnoid hemorrhage -Local trauma from the insertion of the needle -An overwhelming infection -A normal finding; the fluid will be sent for testing to determine other factors
A normal finding; the fluid will be sent for testing to determine other factors Explanation: The CSF should be clear and colorless. Pink, blood-tinged, or grossly bloody CSF may indicate a subarachnoid hemorrhage. The CSF may be bloody initially because of local trauma but becomes clearer as more fluid is drained. Specimens are obtained for cell count, culture, glucose, protein, and other tests as indicated. The specimens should be sent to the laboratory immediately because changes will take place and alter the result if the specimens are allowed to stand.
Which of the following types of skull fractures may be evident by Battle's sign? -Simple -Basilar -Comminuted -Depressed
Basilar Explanation: A clinical manifestation of a basilar skull fracture is the Battle's sign (an area of ecchymosis may be seen over the mastoid). A simple (linear) fracture is a break in continuity of the bone. A comminuted skull fracture refers to a splintered fracture line. When bone fragments are embedded into the brain tissue, the fracture is depressed.
What part of the brain controls and coordinates muscle movement? -Cerebellum -Cerebrum -Midbrain -Brain stem
Cerebellum Explanation: The cerebellum, which is located behind and below the cerebrum, controls and coordinates muscle movement.
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? -Orange juice -Toast -Eggs -Coffee
Coffee Explanation: 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. However, the meal itself is not omitted, because an altered blood glucose level can cause changes in brain wave patterns.
The critical care nurse is giving report on a client they are 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 on-coming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? -Comatose -Stupor -Somnolence -Normal
Comatose Explanation: 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.
While completing a health history on a patient who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state? -Body rigidity -Urinary incontinence -Epileptic cry -Confusion
Confusion Explanation: In the postictal state (after the seizure), the patient is often confused and hard to arouse and may sleep for hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chest muscles that occur during the seizure. Urinary incontinence and intense rigidity of the entire body are followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction) during the seizure.
A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test? -Immobilize the neck before the client is moved onto a stretcher. -Determine whether the client is allergic to iodine, contrast dyes, or shellfish. -Place a cap over the client's head. -Administer a sedative as ordered.
Determine whether the client is allergic to iodine, contrast dyes, or shellfish. Explanation: Because CT commonly involves use of a contrast agent, the nurse should determine whether the client is allergic to iodine, contrast dyes, or shellfish. Neck immobilization is necessary only if the client has a suspected spinal cord injury. Placing a cap over the client's head may lead to misinterpretation of test results; instead, the hair should be combed smoothly. The physician orders a sedative only if the client can't be expected to remain still during the CT scan.
The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke? -Periorbital edema -Dysrhythmias -Projectile vomiting -Facial droop
Facial droop Explanation: Facial drooping or asymmetry is a classic abnormal finding on a physical assessment that may be associated with a stroke. Facial edema is not suggestive of a stroke and clients less commonly experience dysrhythmias or vomiting.
A nurse is caring for a client diagnosed with Ménière disease. While completing a neurologic examination on the client, the nurse assesses cranial nerve VIII. The nurse would be correct in identifying the function of this nerve as what? -Movement of the tongue -Sense of smell -Hearing and equilibrium -Visual acuity
Hearing and equilibrium Explanation: Cranial nerve VIII (acoustic) is responsible for hearing and equilibrium. Cranial nerve XII (hypoglossal) is responsible for movement of the tongue. Cranial nerve II (optic) is responsible for visual acuity and visual fields. Cranial nerve I (olfactory) functions in sense of smell.
A client with a neurological disorder has difficulty swallowing. The nurse should take special care with the client's diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing? -Offer liquids frequently, in large quantities -Instruct the client to lie on the bed when eating -Help the client sit upright when eating and feed slowly -Allow optimum physical activity before meals to expedite digestion
Help the client sit upright when eating and feed slowly Explanation: A client who has impaired swallowing should be helped to eat foods with texture. The nurse should help such a client sit upright, flex the client's chin toward the chest, and feed slowly. These measures promote easy swallowing of food and reduce the risk of aspiration or airway obstruction. The client should be allowed to rest before meals because fatigue may interfere with coordination and following instructions. Liquids should be offered frequently but in small quantities.
A nurse is planning discharge for a client who experienced right-sided weakness caused by a stroke. During his hospitalization, the client has been receiving physical therapy, occupational therapy, and speech therapy daily. The family voices concern about rehabilitation after discharge. How should the nurse intervene? -Suggest that the family members speak with the physician about their concerns. -The nurse should do nothing because she is responsible only for inpatient care. -Inform the case manager of the family's concern and provide information about the client's current clinical status so appropriate resources can be provided after discharge. -Contact the appropriate agencies so that they can provide care after discharge.
Inform the case manager of the family's concern and provide information about the client's current clinical status so appropriate resources can be provided after discharge. Explanation: As the coordinator of care, the nurse must assess the client's needs and initiate referrals for the appropriate health team members to coordinate services needed after discharge. The nurse isn't responsible for contacting agencies to provide care after discharge. Simply providing information about the family's concerns doesn't ensure that services will be arranged for the client after discharge. Alerting the physician is helpful; however, that step doesn't ensure that the necessary services will be provided after discharge. Doing nothing is irresponsible.
What is the function of cerebrospinal fluid (CSF)? -It acts as an insulator to maintain a constant spinal fluid temperature. -It cushions the brain and spinal cord. -It produces cerebral neurotransmitters. -It acts as a barrier to bacteria.
It cushions the brain and spinal cord. Explanation: CSF is produced primarily in the lateral ventricles of the brain. It acts as a shock absorber and cushions the spinal cord and brain against injury caused by sudden or extreme movement. CSF also functions in the removal of waste products from cerebral tissue. CSF doesn't act as an insulator or a barrier and it doesn't produce cerebral neurotransmitters.
The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient? -Assessment of pupillary light reflexes -Determination of the cause -Maintenance of a patent airway -Positioning to prevent complications
Maintenance of a patent airway Explanation: The first priority of treatment for the patient with altered LOC is to obtain and maintain a patent airway.
A client is brought to the ER following a motor vehicle accident in which he sustained head trauma. Preliminary assessment reveals a vision deficit in the client's left eye. The nurse should associate this abnormal finding with trauma to what cerebral lobe? -Temporal -Occipital -Parietal -Frontal
Occipital Explanation: The posterior lobe of the cerebral hemisphere is responsible for visual interpretation. The temporal lobe contains the auditory receptive areas. The parietal lobe contains the primary sensory cortex, and is essential to an individual's awareness of the body in space, as well as orientation in space and spatial relations. The frontal lobe functions in concentration, abstract thought, information storage or memory, and motor function.
A patient is recovering from intracranial surgery that was performed using the transsphenoidal approach. The nurse should be aware that the patient may have required surgery on what neurologic structure? -Pineal gland -Cerebellum -Hypothalamus -Pituitary gland
Pituitary gland Explanation: The transsphenoidal approach (through the mouth and nasal sinuses) is often used to gain access to the pituitary gland. This surgical approach would not allow for access to the pineal gland, cerebellum, or hypothalamus.
A nurse conducts the Romberg test on a client 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 saves the client from being injured. How should the nurse interpret the client's result? -Negative Romberg test, indicating a problem with vision -Positive Romberg test, indicating a problem with equilibrium -Negative Romberg test, indicating a problem with body mass -Positive Romberg test, indicating a problem with level of consciousness
Positive Romberg test, indicating a problem with equilibrium Explanation: If the client sways and starts to fall during the Romberg test, it indicates a positive result. This means the client has a problem with equilibrium. The examiner or the nurse stands fairly close to the client during the test to prevent the client from falling. The Romberg test is used to assess the client's motor function, including muscle movement, size, tone, strength, and coordination. However, the Romberg test is not used to assess the client's level of consciousness, body mass, or vision.
A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize what action? -Removing all metal-containing objects -Initiating an IV line for administration of contrast -Instructing the patient to void prior to the MRI -Withholding stimulants 24 to 48 hours prior to exam
Removing all metal-containing objects Explanation: Client preparation for an MRI consists of removing all metal-containing objects prior to the examination. Withholding stimulants would not affect an MRI; this relates to an electroencephalography (EEG). Instructing the client to void is client preparation for a lumbar puncture. Initiating an IV line for administration of contrast would be done if the client was having a CT scan with contrast.
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? -Risk for impaired skin integrity -Risk for falls -Decreased intracranial adaptive capacity -Risk for aspiration
Risk for aspiration Explanation: CN X, the vagus nerve, involves the gag reflex, laryngeal hoarseness, swallowing ability, and symmetrical rise of the uvula and soft palate. An impaired gag reflex indicates a danger for aspiration and subsequent pneumonia. An impaired vagus nerve will not affect balance, skin integrity, or intracranial adaptive capacity.
The nursing instructor is talking with her clinical group about the central nervous system. What should the instructor tell the students about the function of the spinal cord? -Provides centers for planned action -Extends through the whole vertebral column -Supports the skeletal system -Serves as a conduit for impulses to and from the brain
Serves as a conduit for impulses to and from the brain Explanation: 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. The spinal cord ends between the first and second lumbar vertebrae. The spinal column supports the skeletal system.
The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client who has an aneurysm? -The stimulation can increase intracranial pressure (ICP) or trigger a seizure. -The interaction may cause migraine in the client. -The interaction may cause the client to become violent. -The client may become emotional and lose interest in the treatment.
The stimulation can increase intracranial pressure (ICP) or trigger a seizure. Explanation: Although visitors' and family members' desire to interact with the client are well intentioned, the stimulation can increase ICP or trigger a seizure. The nurse can suggest that they take turns and stay briefly. Interactions are not likely to make the clients violent or emotional, which may cause the client to lose interest in the treatment. The interactions also may not cause migraine in the client.
A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing? -Provide oxygen or anticonvulsants, whichever is available -Place a cooling blanket beneath the client -Suction the client's mouth and pharynx -Turn the client to the side during a seizure and do not restrain movements
Turn the client to the side during a seizure and do not restrain movements Explanation: When a client is in a seizure, the nurse should turn the client to the side and not restrain his or her movements. This helps reduce the potential for aspiration of saliva or stomach contents. The nurse should suction the mouth and pharynx after a seizure has occurred, not during the seizure. Anticonvulsants may be administered to reduce the chances of seizure. Oxygen should not be given to clients with seizures. Clients with respiratory distress are given oxygen. Finally, a cooling blanket is placed beneath the client when hyperthermia occurs, not a seizure.
The nurse is caring for a client newly diagnosed with multiple sclerosis who is overwhelmed by learning about the disease. The client indicates understanding that there is a disruption in the covering of axons but does not remember what the covering is called. The nurse should tell the client: -that because there is so much to learn, there will be another meeting to discuss it again. -that the disease process requires more research. -not to worry about the fine details. -that the covering is called myelin and that it can be discussed further at the next meeting.
that the covering is called myelin and that it can be discussed further at the next meeting. Explanation: The nurse would be most correct in answering the question and then, if the client is tired, following up at the next meeting. It would also be appropriate to provide literature for the client to review at leisure. Discounting the client's need to know information about the disease process is belittling. Telling the client that more research needs to be done discounts the valuable information which is known.
