Theory Exam 3, Brunner Chapter 65 and 66

The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart?

CN II **The nurse assesses vision and thus the optic nerve (cranial nerve II) by use of a Snellen eye chart.

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?

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. However, the meal itself is not omitted, because an altered blood glucose level can cause changes in brain wave patterns.

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 trigger status epilepticus. **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 Therefore, the drug should be withdrawn gradually and not abruptly.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.

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?

Lateral recumbent, with chin resting on flexed knees **To maximize the space between the vertebrae, the client is placed in a lateral recumbent position with knees flexed toward the chin. The needle is inserted between L4 and L5. The other positions wouldn't allow as much space between L4 and L5.

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. **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.

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 **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.

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?

Risk for falls **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 experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with:

body temperature control. **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 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?

"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 nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient?

Maintenance of a patent airway **The first priority of treatment for the patient with altered LOC is to obtain and maintain a patent airway.

A client with meningitis has a history of seizures. Which activity should the nurse do while the client is actively seizing?

Turn the client to the side during a seizure and do not restrain movements **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.

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 will seal the hole in the dura and prevent further loss of cerebral spinal fluid." **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.

The nurse is assessing the client's mental status . Which question will the nurse include in the assessment?

"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. "Can you count backward from 100?" assesses the client's intellectual function. "Are you having hallucinations?" assesses the client's thought content.

Which medication classification is used preoperatively to decrease the risk of postoperative seizures?

Anticonvulsants **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.

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. **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.

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?

Encourage the client to drink liberal amounts of fluids **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 client is administered antihistamines before a test only if he or she is allergic to contrast dye and contrast dye will be used. The room of the client who has undergone a lumbar puncture should be kept dark and quiet. The client should be encouraged to rest, because sensory stimulation tends to magnify discomfort.

A male client is scheduled for an electroencephalogram (EEG). When the nurse caring for the client is preparing him for the test, the client states that during childhood he was mildly electrocuted but miraculously lived. Therefore, he is quite afraid of going through an EEG. In what ways can the nurse help dispel the client's fear regarding the test?

Inform the client that he will not experience any electrical shock. **An EEG records the electrical impulses generated by the brain. To prepare the client for the test, the nurse informs the client that he or she will not experience any electrical shock. The source of electrical energy is the client's neural activity within the brain and not any external electrical energy. Ensuring adequate water intake or distracting the attention of the client will not comfort the client about the technical nature of the test.

What is the function of cerebrospinal fluid (CSF)?

It cushions the brain and spinal cord. **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.

Which of the following is an age-related change in the nervous system?

Loss of neurons in the brain **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 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?

Positive Romberg test, indicating a problem with equilibrium **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 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 aspiration **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 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.

Unequal pupils Pinpoint pupils Absence of pupillary response **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 is scheduled for standard EEG testing to evaluate a possible seizure disorder. Which nursing intervention should the nurse perform before the procedure?

Withhold anticonvulsant medications for 24 to 48 hours before the exam **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.

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:

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. 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 completing a neurological assessment and uses the whisper test to assess which cranial nerve?

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.

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?

"Are you allergic to seafood or iodine?" **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.

A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction?

"Avoid stimulants and alcohol for 24 to 48 hours before the test." **For 24 to 48 hours before an EEG, the client should avoid coffee, cola, tea, alcohol, and cigarettes because these may interfere with the accuracy of test results. (For the same reason, the client also should avoid antidepressants, sedatives, and anticonvulsants.) To avoid a reduced serum glucose level, which may alter test results, the client should eat normal meals before the test. The hair should be washed before an EEG because the electrodes must be applied to a clean scalp. The client's thoughts don't affect the test results.

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 normal finding; the fluid will be sent for testing to determine other factors **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.

The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child?

An absence seizure **Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. Both myoclonic and tonic-clonic seizures involve jerking movements.

A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first?

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 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.

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?

Assist the client to the floor, in a side-lying position, and protect him with linens. **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.

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 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.

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure?

Generalized **A generalized seizure causes generalized electrical abnormality in the brain. The client typically falls to the ground, losing consciousness. The body stiffens (tonic phase) and then alternates between episodes of muscle spasm and relaxation (clonic phase). Tongue biting, incontinence, labored breathing, apnea, and cyanosis may also occur. A Jacksonian seizure begins as a localized motor seizure. The client experiences a stiffening or jerking in one extremity, accompanied by a tingling sensation in the same area. Absence seizures occur most commonly in children. They usually begin with a brief change in the level of consciousness, signaled by blinking or rolling of the eyes, a blank stare, and slight mouth movements. Symptoms of a sensory seizure include hallucinations, flashing lights, tingling sensations, vertigo, déjà vu, and smelling a foul odor.

Which cranial nerve is responsible for muscles that move the eye and lids?

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.

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event?

Seizure was 1 minute in duration including tonic-clonic activity. **Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and their skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity.

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:

carefully move the client to a flat surface and turn him on his side. **When caring for a client experiencing a tonic-clonic seizure, the nurse should help the client to a flat non-elevated surface and then position him on his side to ensure that he doesn't aspirate and to protect him from injury. These steps help reduce the risk of injury from falling or hitting surrounding objects and help establish an open airway. The client shouldn't be restrained during the seizure. Also, nothing should be placed in his mouth; anything in the mouth could impair ventilation and damage the inside of the mouth.

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 **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.

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?

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.

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?

Confusion **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.

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 **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.