Week 8: Neurologic System
A patient with an addiction to alcohol checked into a rehabilitation center. He experiences delirium, inability to concentrate, and is easily distracted. From which of the following is he most likely suffering? a. Acute confusional state b. Echolalia c. Dementia d. Dysphagia
ANS: A Delirium and the inability to concentrate are characteristics of acute confusional state. Echolalia is the repeating of words and phrases. Dementia is characterized by loss of recent and remote memory. Dysphagia is difficulty speaking.
When a student asks what can cause dilated, fixed pupils, what is the nurse's best response? Dilated fixed pupils can be caused by: a. Brainstem hypoxia b. Cerebral contusions c. Compression of the hypothalamus d. Spinal shock
ANS: A Dilated fixed pupils are caused by brainstem hypoxia.
A 45-year-old male presents with seizures. An MRI reveals a meningioma most likely originating from the: a. Dura mater and arachnoid membrane b. Astrocytes c. Pia mater d. CNS neurons
ANS: A Meningiomas tumors usually originate from the arachnoidal (meningeal) cap cells in the dura mater. Astrocytes are found in the brain, but are not related to meningiomas. The pia mater is the location of the infection meningitis. Neurons are located throughout all regions of the brain.
A 20-year-old male is admitted to the neurological critical care unit with a severe closed head injury. When an intraventricular catheter is inserted, the ICP is recorded at 24 mm Hg. How should the nurse interpret this reading? This reading is: a. Higher than normal b. Lower than normal c. Normal d. Borderline
ANS: A Normal ICP is 5 to 15 mm Hg; at 24 mm Hg, the patient's is higher than normal.
A patient has paralysis of both legs. What type of paralysis does the patient have? a. Paraplegia b. Quadriplegia c. Infraparaplegia d. Paresthesia
ANS: A Paraplegia is the paralysis of both legs. Quadriplegia is the paralysis of all four extremities. Infraparaplegia is not a description of paralysis. Paresthesia is a loss of sensation, not paralysis.
When the spouse of a patient experiencing a thrombotic stroke asks when "clot busting" treatment should begin, how should the nurse respond? Recommendations suggest that treatment for a thrombotic stroke begin within ________ hours of onset of symptoms.
ANS: 3
A cause of hydrocephalus in subarachnoid hemorrhage is: a. Scarring of meninges and impairment of CSF resorption b. Choroid plexus injury c. Impairment of CSF flow through the ventricles d. Vasoconstriction related to carbon dioxide (CO2) changes in the cerebral circulation
ANS: A A primary cause of hydrocephalus is impairment of CSF resorption that allows fluid to accumulate.
While planning care for a patient with an extradural hematoma, which principle should the nurse remember? The main source of bleeding in extradural (epidural) hematomas is: a. Arterial b. Venous c. Capillary d. Sinus
ANS: A An artery is the source of bleeding in 85% of extradural hematomas.
A nurse notes that a patient walks with the leg extended and held stiff, causing a scraping over the floor surface. What type of gait is the patient experiencing? a. Spastic gait b. Cerebellar gait c. Basal ganglion gait d. Scissors gait
ANS: A An individual who walks with the leg extended and held stiff, causing a scraping over the floor surface, is experiencing a spastic gait. A cerebellar gait is wide-based with the feet apart and often turned outward or inward for greater stability. A basal ganglion gait occurs when the person walks with small steps and a decreased arm swing. A scissors gait is associated with bilateral injury and spasticity. The legs are abducted so they touch each other.
An attorney spoke to the nurses regarding brain death. Which statement indicates the nurses understood brain death? For legal purposes, brain death is defined as: a. Cessation of brain function b. Lack of cortical function c. A VS d. Death of the brainstem
ANS: A Brain death occurs when there is cessation of function of the entire brain, including the brainstem and cerebellum. Lack of cortical function is not enough to define brain death. A VS is complete unawareness of the self or surrounding environment and complete loss of cognitive function. Brain death occurs when there is cessation of function of the entire brain, including the brainstem and cerebellum, not just the brainstem.
The patient is experiencing an increase in intracranial pressure. This increase results in: a. Brain tissue hypoxia b. Intracranial hypotension c. Ventricular swelling d. Expansion of the cranial vault
ANS: A Brain tissue hypoxia occurs as a result of increased intracranial pressure as it places pressure on the brain. Increased intracranial pressure leads to intracranial hypertension. Ventricular swelling may lead to increased intracranial pressure, but increased pressure does not lead to ventricular swelling. Expansion of the cranial vault may lead to increased intracranial pressure, but increased pressure does not lead to expansion of the vault.
The breathing pattern that reflects respirations based primarily on carbon dioxide (CO2) levels in the blood is: a. Cheyne-Stokes b. Ataxic c. Central neurogenic d. Normal
ANS: A Cheyne-Stokes respirations occur as a result of CO2 levels in the blood. Ataxic breathing occurs as a result of dysfunction of the medullary neurons. Central neurogenic patterns occur as a result of uncal herniation. Normal respirations are based on the levels of oxygen (O2) in the blood.
A 25-year-old male was in an automobile accident. At impact, his forehead struck the windshield. In this situation, a nurse recalls the coup injury would occur in the _____ region. a. Frontal b. Temporal c. Parietal d. Occipital
ANS: A Coup injuries move forward and affect the frontal region of the brain. Coup injuries affect the frontal region of the brain as the brain moves forward, not to the side or temporal region. Contrecoup injuries affect the rear or occipital region.
Of the following groups, who are at highest risk for a cerebrovascular accident (CVA)? a. Blacks over 65 years of age b. Whites over 65 years of age c. Blacks under 65 years of age d. Whites under 65 years of age
ANS: A The individuals at highest risk for cerebrovascular accident would be blacks over 65. Blacks are at greater risks than whites. Older adults are at greater risk than younger adults.
A neurologist is teaching about brain injuries. Which information should the neurologist include? The most severe diffuse brain injury caused by rotational acceleration is most likely to be located _____ the brainstem. a. More peripheral to b. In the central portion of c. Throughout d. Distal to
ANS: A The most severe axonal injuries are located more peripheral to the brainstem.
A 15-month-old child from Pennsylvania was brought to the ER for fever, seizure activity, cranial palsies, and paralysis. Which of the following diagnosis will be documented in the chart? a. Eastern equine encephalitis b. Venezuelan encephalitis c. St. Louis encephalitis d. West Nile encephalitis
ANS: A The symptoms indicate encephalitis, and given the residence of the child and the symptoms, the diagnosis is Eastern equine encephalitis. Venezuelan occurs in Texas, Florida, and the South. St. Louis occurs in Canada and the Pacific coast. West Nile occurs throughout the United States, but primarily affects the elderly.
A 75-year-old male experienced a lacunar stroke. When looking through the history of the patient's chart, which of the following would the nurse expect to find? a. An embolus b. Hypertension c. A hemorrhage d. An aneurysm
ANS: B A lacunar stroke is associated with hypertension.
A patient is admitted with amyotrophic lateral sclerosis (ALS). Which classic assessment findings will support the diagnosis of ALS? a. Progressive dementia b. Muscle weakness and atrophy c. Severe paresthesias d. Autonomic dysfunctions
ANS: B ALS is manifested by muscle weakness and atrophy.
A 65-year-old male recently suffered a cerebral vascular accident. He is now unable to recognize and identify objects by touch because of injury to the sensory cortex. How should the nurse document this finding? a. Hypomimesis b. Agnosia c. Dysphasia d. Echolalia
ANS: B Agnosia is the failure to recognize the form and nature of objects. Hypomimesis is a disorder of communication. Dysphasia is an impairment of comprehension of language. Echolalia is the ability to repeat.
A 10-year-old female was brought to the ER following a sudden onset of convulsions. The primary care provider thinks that she experienced an explosive, disorderly discharge of cerebral neurons referred to as: a. Reflex b. Seizure c. Inattentiveness d. Brain death
ANS: B An explosive disorderly discharge of neurons is a seizure. A reflex is an expected response. Inattentiveness is a form of neglect. Brain death is a cessation of function.
An infant is diagnosed with noncommunicating hydrocephalus. What is an immediate priority concern for this patient? a. Metabolic edema b. Interstitial edema c. Vasogenic edema d. Ischemic edema
ANS: B An immediate concern for the infant with noncommunicating hydrocephalus is interstitial edema.
Which information indicates the nurse understands assessment findings of an aneurysm? a. A headache is the most common symptom b. The majority are asymptomatic c. Nosebleeds are an early symptom d. Epidural hemorrhage occurs in over 80% of patients
ANS: B Aneurysms often are asymptomatic.
A 25-year-old female presents to her primary care provider reporting fever, headache, nuchal rigidity, and decreased consciousness. She was previously treated for sinusitis. Which of the following is the most likely diagnosis? a. Aseptic meningitis b. Bacterial meningitis c. Fungal meningitis d. Nonpurulent meningitis
ANS: B Bacterial meningitis can occur secondary to sinusitis and is manifested by fever, tachycardia, chills, and a petechial rash with a severe throbbing headache, severe photophobia, and nuchal rigidity. The clinical manifestations of aseptic meningitis are milder than bacterial meningitis and are not associated with a previous infection such as sinusitis. Fungal meningitis presents as dementia. Nonpurulent meningitis is the same as aseptic and is milder and not associated with conditions such as sinusitis.
A 69-year-old male with a history of alcohol abuse presents to the emergency room (ER) after a month-long episode of headaches and confusion. Based on his alcoholism, a likely cause of his neurologic symptoms is: a. Concussion b. Chronic subdural hematoma c. Epidural hematoma d. Subacute subdural hematoma
ANS: B Chronic subdural hematomas are commonly found in persons who abuse alcohol and develop over weeks to months. A concussion is more acute, and chronic subdural hematomas are more commonly found in persons who abuse alcohol. It is a chronic subdural hematoma that occurs in alcoholics, not an epidural. Subacute subdural hematomas present with confusion, but these occur sooner than the chronic subdural associated with alcoholism.
When a patient asks how bad the injuries will be from a spinal injury, what is the nurse's best response? It is difficult to know the full extent of the injury because of: a. Incomplete transection of the spinal cord b. Swelling within the spinal cord c. Necrosis of the spinal cord d. Free radical injury and scarring of the glial cells
ANS: B Cord swelling increases the individual's degree of dysfunction, so it is hard to distinguish functions permanently lost from those temporarily impaired.
A 16-year-old male fell off the bed of a pickup truck and hit his forehead on the road. He now has resistance to passive movement that varies proportionally with the force applied. He is most likely suffering from: a. Spasticity b. Gegenhalten c. Rigidity d. Dystonia
ANS: B Gegenhalten is manifested by resistance to passive movement that varies in direct proportion to force applied. Spasticity is manifested by a gradual increase in tone causing increased resistance until tone suddenly reduces. Rigidity is manifested by muscle resistance to passive movement of a rigid limb that is uniform in both flexion and extension throughout the motion. Dystonia is manifested by sustained involuntary twisting movement.
A 15-year-old male suffered diffuse brain injury after wrecking an all-terrain vehicle. He had momentary confusion and retrograde amnesia after 5 to 10 minutes. His injury could be categorized as: a. Grade I b. Grade II c. Grade III d. A mild concussion
ANS: B Grade II is manifested as momentary confusion and retrograde amnesia after 5 to 10 minutes. Grade I is manifested by confusion and disorientation with momentary amnesia. Grade III is manifested by confusion and retrograde amnesia from impact—also anterograde amnesia. A mild concussion does not result in memory loss.
A 40-year-old male complains of uncontrolled excessive movement and progressive dysfunction of intellectual and thought processes. He is experiencing movement problems that begin in the face and arms that eventually affect the entire body. The most likely diagnosis is: a. Tardive dyskinesia b. Huntington disease c. Hypokinesia d. Alzheimer disease
ANS: B Huntington disease is manifested by chorea, abnormal movement that begins in the face and arms, eventually affecting the entire body. There is progressive dysfunction of intellectual and thought processes. Tardive dyskinesia is manifested by rapid, repetitive, stereotypic movements. Most characteristic is continual chewing with intermittent protrusions of the tongue, lip smacking, and facial grimacing. Hypokinesia is loss of voluntary movement despite preserved consciousness and normal peripheral nerve and muscle function. Alzheimer disease is manifested by cognitive deficits and not movement problems; motor impairments will occur in the later stages.
A 10-year-old male was climbing on a house and fell. He suffered a severe brain injury. His Glasgow Coma Scale (GCS) was 5 initially and 7 after 1 day. He remained unconscious for 2 weeks, then was confused and suffered from anterograde amnesia. Which of the following is he most likely experiencing? a. Mild diffuse brain injury b. Moderate diffuse brain injury c. Severe diffuse brain injury d. Postconcussive syndrome
ANS: B In moderate diffuse axonal injury, the score on the GCS is 4 to 8 initially and 6 to 8 by 24 hours and the person is confused and suffers a long period of posttraumatic anterograde and retrograde amnesia. Individuals who experience diffuse brain injury experience agitation, impulsiveness, blunted affect, social withdrawal, and depression. In severe diffuse axonal injury, the person experiences immediate autonomic dysfunction that disappears in a few weeks. Increased ICP appears 4 to 6 days after the injury. In postconcussive syndrome the individual experiences headache, nervousness or anxiety, irritability, insomnia, depression, inability to concentrate, forgetfulness, and fatigability.
A 39-year-old male suffers a severe brain injury when he falls off a building while working. CT scan reveals that he has a basilar skull fracture. Based upon his injuries, what major complication should the nurse observe for in this patient? a. Hematoma formation b. Meningeal infection c. Increased intracranial pressure (ICP) d. Cognitive deficits
ANS: B Individuals with basilar skull fractures should be observed for meningitis and other complications.
A male patient complains of tiring easily, has difficulty rising from a sitting position, and cannot stand on his toes. The nurse would expect a diagnosis of: a. Parkinson disease b. Hypotonia c. Huntington disease d. Paresis
ANS: B Individuals with hypotonia tire easily (asthenia) or are weak. They may have difficulty rising from a sitting position, sitting down without using arm support, and walking up and down stairs, as well as an inability to stand on their toes. Individuals with Parkinson disease have rigidity and stiffness. Symptoms of Huntington disease include irregular, uncontrolled, and excessive movement. Paresis, or weakness, is partial paralysis with incomplete loss of muscle power.
When thought content and arousal level are intact but a patient cannot communicate, the patient has: a. Cerebral death b. Locked-in syndrome c. Dysphagia d. Cerebellar motor syndrome
ANS: B Locked-in syndrome occurs when the individual cannot communicate through speech or body movement but is fully conscious, with intact cognitive function. In cerebral death the person is in a coma with eyes closed. Dysphagia is difficulty speaking Cerebellar motor syndrome is characterized by problems with coordinated movement.
A neurologist is teaching about encephalitis. Which information should the neurologist include? Most causes of encephalitis are: a. Bacterial b. Viral c. Fungal d. Toxoid
ANS: B Most causes of encephalitis are viral.
A 16-year-old male took a recreational drug that altered his level of arousal. Physical exam revealed a negative Babinski sign, equal and reactive pupils, and roving eye movements. Which of the following diagnosis will the nurse most likely see on the chart? a. Psychogenic arousal alteration b. Metabolically induced coma c. Structurally induced coma d. Structural arousal alteration
ANS: B Persons with metabolically induced coma generally retain ocular reflexes even when other signs of brainstem damage are present. Psychogenic arousal activation demonstrates a general psychiatric disorder. Structurally induced coma is manifested by asymmetric responses. Structural arousal alteration does not have drug use as its etiology.
A 25-year-old male died from a gunshot wound to the heart. Upon autopsy, abnormalities in the media of the arterial wall and degenerative changes were detected. Which of the following most likely accompanied this finding? a. Fusiform aneurysm b. Saccular aneurysm c. Arteriovenous malformation d. Thrombotic stroke
ANS: B Saccular aneurysms (berry aneurysms) occur frequently (in approximately 2% of the population) and likely result from congenital abnormalities in the media of the arterial wall and degenerative changes. Fusiform aneurysms (giant aneurysms) occur as a result of diffuse arteriosclerotic changes and are found most commonly in the basilar arteries or terminal portions of the internal carotid arteries. Arteriovenous malformation (AVM) is a tangled mass of dilated blood vessels creating abnormal channels between the arterial and venous systems. Thrombotic stroke would show signs of necrotic tissue, not degenerative changes.
Which principle should the nurse remember while planning care for a patient with spinal shock? Spinal shock is characterized by: a. Loss of voluntary motor function with preservation of reflexes b. Cessation of spinal cord function below the lesion c. Loss of spinal cord function at the level of the lesion only d. Temporary loss of spinal cord function above the lesion
ANS: B Spinal shock is the complete cessation of spinal cord function below the lesion. The reflexes are not preserved in spinal shock.
A 51-year-old male is admitted to the neurological critical care unit with a severe closed head injury. All four extremities are in rigid extension, his forearm is hyperpronated, and his legs are in plantar extension. How should the nurse chart this condition? a. Decorticate posturing b. Decerebrate posturing c. Caloric posturing d. Excitation posturing
ANS: B The description is of a patient in decerebrate posturing.
The patient reports generalized muscle weakness. The health care provider orders administration of the medication edrophonium chloride (Tensilon). This medication is used in the diagnosis of: a. Amyotrophic lateral sclerosis b. Myasthenia gravis c. MS d. Autonomic hyperreflexia
ANS: B The diagnosis of myasthenia gravis is made on the basis of a response to edrophonium chloride (Tensilon).
A 23-year-old female begins having problems with tiredness, weakness, and visual changes. Her diagnosis is multiple sclerosis (MS). What is occurring in the patient's body? a. Depletion of dopamine in the central nervous system (CNS) b. Demyelination of nerve fibers in the CNS c. The development of neurofibril webs in the CNS d. Reduced amounts of acetylcholine at the neuromuscular junction
ANS: B The pathophysiology of MS includes demyelination of nerve fibers. Depletion of dopamine is related to Parkinson disease. The development of neurofibrils is related to Alzheimer disease. Myasthenia gravis is due to decreased amounts of acetylcholine at the junction.
A 15-year-old male is brought to the ER for treatment of injuries received in a motor vehicle accident. An MRI reveals spinal cord injury, and his body temperature fluctuates markedly. The most accurate explanation of this phenomenon is that: a. He developed pneumonia. b. His sympathetic nervous system has been damaged and thermal control disturbed. c. He has a brain injury. d. He has septicemia from an unknown source.
ANS: B The patient experiences disturbed thermal control because the sympathetic nervous system is damaged. The hypothalamus cannot regulate body heat through vasoconstriction and increased metabolism; therefore, the individual assumes the temperature of the air.
The primary care provider states that the patient has vasogenic edema. The nurse realizes vasogenic edema is clinically important because: a. It usually has an infectious cause. b. The blood-brain barrier is disrupted. c. Increased intracranial pressure (ICP) is excessively high. d. It always causes herniation.
ANS: B Vasogenic edema is clinically important because the blood-brain barrier (selective permeability of brain capillaries) is disrupted, and plasma proteins leak into the extracellular spaces. Vasogenic does not have an infectious cause. ICP is increased, but not more so than other forms of edema. Vasogenic edema disrupts the blood-brain barrier, but it does not always cause herniation.
A 20-year-old male suffers a severe closed head injury in a motor vehicle accident. He remains in a vegetative state (VS) 1 month after the accident. Which of the following structures is most likely keeping him in a vegetative state? a. Cerebral cortex b. Brainstem c. Spinal cord d. Cerebellum
ANS: B When a person loses cerebral function, the reticular activating system and brainstem can maintain a crude waking state known as a VS. Cognitive cerebral functions, however, cannot occur without a functioning reticular activating system.
A 48-year-old female presents at the ER reporting an acute severe headache, nausea, photophobia, and nuchal rigidity. What does the nurse suspect caused these signs and symptoms? a. Diffuse brain injury b. Subarachnoid hemorrhage c. Epidural hematoma d. Classic concussion
ANS: B With subarachnoid hemorrhage, meningeal irritation occurs, leading to nuchal rigidity.
A 30-year-old female had a seizure that started with her fingers and progressive1y spread up her arm and then extended to her leg, with no loss of consciousness. How should the nurse chart this? a. Myoclonic seizure b. Tonic-clonic seizure c. Focal motor seizure d. Atonic seizure
ANS: C A focal motor seizure involves the extremities and the patient does not experience loss of consciousness. A myoclonic seizure involves symmetrical movements of selected extremities. A tonic-clonic seizure involves all body parts and loss of consciousness. An atonic seizure is without muscle tone.
A neurologists explains that arousal is mediated by the: a. Cerebral cortex b. Medulla oblongata c. Reticular activating system d. Cingulate gyrus
ANS: C Arousal is mediated by the reticular activating system, which regulates aspects of attention and information processing and maintains consciousness.
Which statement by the nurse indicates teaching was successful regarding CNS tumors in adults? The most common primary CNS tumors in adults are: a. Meningiomas b. Oligodendrogliomas c. Astrocytomas d. Ependymomas
ANS: C Astrocytomas are the most common primary tumors in the CNS, accounting for over 50%. Meningiomas tumors usually originate from the arachnoidal (meningeal) cap cells in the dura mater and account for 30% of tumors. Oligodendrogliomas account for about 2% of tumors. Ependymomas are more common in children.
A major contributing process in CVAs is the development of atheromatous plaques in cerebral circulation. These most commonly form: a. In the larger veins b. Near capillary sphincters c. In cerebral arteries d. In the venous sinuses
ANS: C Atheromatous plaques (stenotic lesion) form at branchings and curves in the cerebral circulation. Over 20 to 30 years, atheromatous plaques (stenotic lesion) form at branchings and curves in the cerebral circulation, primarily the arteries.
A compensatory alteration in the diameter of cerebral blood vessels in response to increased intracranial pressure is called: a. Herniation b. Vasodilation c. Autoregulation d. Amyotrophy
ANS: C Autoregulation is the compensatory alteration in the diameter of the intracranial blood vessels designed to maintain a constant blood flow during changes in cerebral perfusion pressure. Herniation is the downward protrusion of the brainstem. Vasodilation is an enlargement in vessel diameter and a part of autoregulation, but the vessels should not dilate in the presence of increased intracranial pressure. Amyotrophy is involved with the anterior horn cells of the spinal cord and not related to autoregulation.
A patient has excessive movement. What disorder will the nurse see documented on the chart? a. Hypokinesia b. Akinesia c. Hyperkinesia d. Dyskinesia
ANS: C Excessive movement is the definition of hyperkinesia. Hypokinesia is decreased movement. Akinesia is loss of movement. Dyskinesia is abnormal movement.
A 33-year-old male is brought to the ER for treatment of injuries received in a motor vehicle accident. An MRI reveals an injury of the cervical cord. Cord swelling in this region may be life threatening because: a. Increased ICP may occur. b. Reflexes will be disrupted. c. Diaphragm function may be impaired. d. Bladder emptying will not occur.
ANS: C In the cervical region, cord swelling may be life threatening because it may impair the diaphragm function.
A 65-year-old female loses her balance while walking in the woods, causing her to fall and hit her head. She loses consciousness and is in a coma for 5 days. She is diagnosed as having diffuse brain injury. Which of the following would most likely occur in this patient? a. Complete loss of vision b. Arrhythmia c. Blunted affect d. Meningitis infection
ANS: C Individuals who experience diffuse brain injury experience agitation, impulsiveness, blunted affect, social withdrawal, and depression.
A 15-year-old male was struck by a motor vehicle and suffered a traumatic brain injury. Paramedics found him unconscious at the scene of the accident. During the ambulance ride, he regained consciousness and was able to maintain a conversation with the medical staff. Upon arrival to hospital, he was alert and oriented. Physical exam reveals confusion and impaired responsiveness. What is the probable nature of his brain injury based on this history? a. Mild concussion b. Subdural hematoma c. Extradural (epidural) hematoma d. Mild diffuse axonal injury
ANS: C Individuals with extradural hematomas lose consciousness at injury; one-third then become lucid for a few minutes to a few days. Mild concussion is characterized by immediate but transitory confusion that lasts for one to several minutes, possibly with amnesia for events preceding the trauma. Subdural hematomas begin with headache, drowsiness, restlessness or agitation, slowed cognition, and confusion. These symptoms worsen over time and progress to loss of consciousness, respiratory pattern changes, and pupillary dilation. Individuals with mild diffuse axonal injury display decerebrate or decorticate posturing and may experience prolonged periods of stupor or restlessness.
Which assessment finding by the nurse characterizes a mild concussion? a. A brief loss of consciousness b. Significant behavioral changes c. Retrograde amnesia d. Permanent confusion
ANS: C Mild concussion is characterized by immediate but transitory confusion that lasts for one to several minutes, possibly with amnesia for events preceding the trauma. Individuals with extradural hematomas lose consciousness at injury; one-third then become lucid for a few minutes to a few days. Persons with diffuse brain injury demonstrate behavioral changes. Individuals with a mild concussion experience transient not permanent confusion.
When a patient asks, "What is the cause of multiple sclerosis?" how should the nurse reply? The cause of MS seems to be an interaction between: a. Vascular and metabolic factors b. Bacterial infection and the inflammatory response c. Autoimmunity and genetic susceptibility d. Neurotransmitters and inherited genes
ANS: C Multiple sclerosis is due to an interaction between the autoimmune response and genetics.
An initial assessment finding associated with acute spinal cord injury is _____ the injury. a. Pain below the level of b. Loss of autonomic reflexes above c. Loss of voluntary control below d. Hyperactive spinal reflexes below
ANS: C Normal activity of the spinal cord cells at and below the level of injury ceases because of loss of the continuous tonic discharge from the brain or brainstem and inhibition of suprasegmental impulses immediately after cord injury, thus causing spinal shock. Pain would not be present below the level of the injury because activity of the cells below the level of injury ceases. Autonomic reflexes above the injury remain intact. Activity of the cells below the level of injury cease; thus, hyperactive spinal reflexes below the injury will not occur.
Patients with myasthenia gravis often have tumors or pathologic changes in the: a. Brain b. Pancreas c. Thymus d. Lungs
ANS: C Patients with myasthenia gravis experience tumors in the thymus.
A patient has memory loss of events that occurred before a head injury. What cognitive disorder does the nurse suspect the patient is experiencing? a. Selective memory deficit b. Anterograde amnesia c. Retrograde amnesia d. Executive memory deficit
ANS: C Retrograde amnesia is manifested by loss of memory of past personal history memories or past factual memories. In selective memory deficit, the person reports inability to focus attention and has failure to perceive objects and other stimuli. Anterograde amnesia is a loss of the ability to form new memories. Executive memory deficit involves the failure to stay alert and oriented to stimuli.
A 50-year-old male presents with low back pain. He denies trauma and says he just woke up and it was hurting. An MRI reveals that the vertebra at L5 slid forward relative to those above and below it. Which of the following conditions will be documented on the chart? a. Degenerative disk disease b. Spondylolysis c. Spondylolisthesis d. Spinal stenosis
ANS: C Spondylolisthesis occurs when there is forward displacement of the deficient vertebra. Degenerative disk disease is a pathophysiological cause of spondylolisthesis, but is not the definition of forward displacement. Spondylolysis is a structural defect of the spine. Spinal stenosis is a narrowing of the spinal canal.
A 70-year-old female is being closely monitored in the neurological critical care unit for a severe closed head injury. After 48 hours, her condition begins to deteriorate. Her pupils are small and sluggish, pulse pressure is widening, and she is bradycardic. These clinical findings are evidence of what stage of intracranial hypertension? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4
ANS: C Stage 3 is characterized by decreasing levels of arousal or central neurogenic hyperventilation, widened pulse pressure, bradycardia, and pupils that become small and sluggish. Stage 1 is characterized by an ICP that may not change because of the effective compensatory mechanisms, and there may be few symptoms. Stage 2 is characterized by subtle and transient symptoms, including episodes of confusion, restlessness, drowsiness, and slight pupillary and breathing changes. Stage 4 is characterized by cessation of cerebral blood flow.
A 20-year-old female suffered from spinal cord injury that resulted from a motor vehicle accident. She had spinal shock lasting 15 days and is now experiencing an uncompensated cardiovascular response to sympathetic stimulation. What does the nurse suspect caused this condition? a. Toxic accumulation of free radicals below the level of the injury b. Pain stimulation above the level of the spinal cord lesion c. A distended bladder or rectum d. An abnormal vagal response
ANS: C The described symptoms indicate autonomic hyperreflexia and are due to a distended bladder or rectum.
A 30-year-old white male recently suffered a cerebrovascular accident. Which of the following is the most likely factor that contributed to his stroke? a. Age b. Gender c. Diabetes d. Race
ANS: C The most likely contributing factor to the patient's stroke is that he has diabetes with a fourfold increase in stroke incidence and an eightfold increase in stroke mortality. Age greater than 65 years is contributing factor. Men are affected, but for the 30-year-old, his type 2 diabetes mellitus contributes to a fourfold increase in stroke incidence and an eightfold increase in stroke mortality. Blacks are affected more than whites, and it is this patient's diabetes that places him at risk.
Six weeks ago a female patient suffered a T6 spinal cord injury. She then developed a blood pressure of 200/120, a severe headache, blurred vision, and bradycardia. What does the nurse suspect the patient is experiencing? a. Extreme spinal shock b. Acute anxiety c. Autonomic hyperreflexia d. Parasympathetic areflexia
ANS: C The patient is experiencing autonomic hyperreflexia, which is manifested by paroxysmal hypertension (up to 300 mm Hg, systolic), a pounding headache, blurred vision, sweating above the level of the lesion with flushing of the skin, nasal congestion, nausea, piloerection caused by pilomotor spasm, and bradycardia (30 to 40 beats/min).
A 60-year-old female with a recent history of head trauma and a long-term history of hypertension presents to the ER for changes in mental status. MRI reveals that she had a hemorrhagic stroke. What does the nurse suspect caused this type of stroke? a. Rheumatic heart disease b. Thrombi c. Aneurysm d. Hypotension
ANS: C The primary causative factor of a hemorrhagic stroke is an aneurysm.
A 45-year-old female presents to the emergency room (ER) reporting excessive vomiting. A CT scan of the brain reveals a mass in the: a. Skull fractures b. Thalamus c. Medulla oblongata d. Frontal lobe
ANS: C Vomiting is due to disruptions in the medulla oblongata.
A 72-year-old male demonstrates left-sided weakness of upper and lower extremities. The symptoms lasted 4 hours and resolved with no evidence of infarction. The patient most likely experienced a(n): a. Stroke in evolution b. Arteriovenous malformation c. Transient ischemic attack d. Cerebral hemorrhage
ANS: C When symptoms resolve with complete recovery, it is a transient ischemic attack. A stroke in evolution is an impending stroke, and symptoms would not resolve. An arteriovenous malformation is an abnormal arrangement of blood vessels that could lead to stroke, but is not a disorder in itself. Cerebral hemorrhage would not resolve.
A 65-year-old male suffers a subarachnoid hemorrhage secondary to uncontrolled hypertension. He appears drowsy and confused with pronounced focal neurologic deficits. This condition is grade: a. I b. II c.III d. IV
ANS: C With grade III, the patient experiences drowsiness and confusion with or without focal neurologic deficits and pronounced meningeal signs. With grade I, neurologic status is intact with mild headache and slight nuchal rigidity. With grade II, neurologic deficit is evidenced by cranial nerve involvement and moderate to severe headache with more pronounced meningeal signs (e.g., photophobia, nuchal rigidity). With grade IV, the patient is stuporous with pronounced neurologic deficits (e.g., hemiparesis, dysphasia) and nuchal rigidity.
A nurse is preparing to teach staff about the most common type of traumatic brain injury. Which type of traumatic brain injury should the nurse discuss? a. Penetrating trauma b. Diffuse axonal injury c. Focal brain injury d. Concussion
ANS: D A concussion is the most common type of traumatic brain injury. Penetrating trauma is due to such items as bullets and is not the most common type of brain injury. Diffuse axonal injury is due to rotation and is not as common as concussions. Focal brain injury is not as common as concussions.
A 20-year-old male was at the supermarket when he fell to the ground. Bystanders reported that he lost consciousness and his body tensed up then relaxed, then tensed and relaxed several times. He most likely was experiencing a(n): a. Partial seizure b. Absence seizure c. Myoclonic seizure d. Tonic-clonic seizure
ANS: D A tonic-clonic seizure involves repeated contraction and relaxation. A partial seizure involves only one body part. An absence seizure is without movement. A myoclonic seizure is a simple seizure with minimal jerking present.
When a patient has a peculiar sensation that immediately precedes a seizure, what term should the nurse use to describe this sensation? a. Prodroma b. Agnosia c. Spasm d. Aura
ANS: D An aura is a peculiar sensation that immediately precedes a seizure. A prodroma is a manifestation that occurs hours preceding a seizure. Agnosia is an inability to recognize objects. A spasm is a jerking action.
As a portion of the assessment of the patient with meningitis, the health care provider flexes the patient's neck to the chest. The patient responds with flexion of the legs and thighs. The name for this response is: a. Decorticate posturing b. Decerebrate posturing c. Kernig's sign d. Brudzinski's sign
ANS: D Brudzinski's sign is demonstrated by flexion of the legs and thighs with forceful flexion of the neck onto the chest. Decorticate posturing occurs when the arms are bent forward on the chest and the hands clenched. Decerebrate posturing occurs when the upper extremities extend. Kernig's sign occurs when the patient straightens the knee with the hip and knee in a flexed position.
A 50-year-old male suffers a severe head injury when his motorcycle hits a tree. His breathing becomes deep and rapid but with normal pattern. What term should the nurse use for this condition? a. Gasping b. Ataxic breathing c. Apneusis d. Central neurogenic hyperventilation
ANS: D Central neurogenic hyperventilation is a sustained, deep, rapid, but regular, pattern (hyperpnea) of breathing. Gasping is a pattern of deep "all-or-none" breaths accompanied by a slow respiratory rate. Ataxic breathing is completely irregular breathing that occurs with random shallow and deep breaths and irregular pauses. Apneusis is manifested by a prolonged inspiratory pause alternating with an end-expiratory pause.
Which of the following would increase a patient's risk for thrombotic stroke? a. Hyperthyroidism b. Hypertension c. Anemia d. Dehydration
ANS: D Dehydration is a risk factor because it increases blood viscosity and decreases cerebral perfusion. Hyperthyroidism would lead to increased blood pressure but does not place the patient at risk for thrombotic stroke. Hypotension, not hypertension is a risk factor for thrombotic stroke. Anemia would decrease a person's risk for thrombotic stroke.
A nurse thinks a patient may be experiencing dementia. Which assessment finding will most help support this diagnosis? a. Violent behavior b. Hyperactivity c. Depression d. Loss of recent and remote memory
ANS: D Dementia is characterized by loss of recent and remote memory.
_____ are most at risk of spinal cord injury from minor trauma. a. Infants b. Men c. Women d. The elderly
ANS: D Elderly people are particularly at risk from minor trauma that results in serious spinal cord injury because of preexisting degenerative vertebral disorders.
An adult has hydrocephalus. When the patient asks the nurse what caused this, how should the nurse respond? Hydrocephalus in adults is most often caused by: a. Overproduction of CSF b. Intercellular edema c. Elevated arterial blood pressure d. Defective CSF reabsorption
ANS: D Hydrocephalus occurs because of defective reabsorption of the fluid. Hydrocephalus can occur because of overproduction of CSF, but in adults it occurs most often because of defective reabsorption of the fluid.
The progress notes read: the cerebellar tonsil has shifted through the foramen magnum due to increased pressure within the posterior fossa. The nurse would identify this note as a description of _____ herniation. a. Supratentorial b. Central c. Cingulated gyrus d. Infratentorial
ANS: D In infratentorial herniation, the cerebellar tonsil shifts through the foramen magnum because of increased pressure within the posterior fossa. Supratentorial herniation involves temporal lobe and hippocampal gyrus shifting from the middle fossa to posterior fossa. Central herniation is a type of supratentorial herniation and is the straight downward shift of the diencephalon through the tentorial notch. Gyrus herniation occurs when the cingulate gyrus shifts under the falx cerebri. Little is known about its clinical manifestations.
Which statement by a patient indicates teaching was successful regarding myasthenia gravis? Myasthenia gravis results from: a. Viral infection of skeletal muscle b. Atrophy of motor neurons in the spinal cord c. Demyelination of skeletal motor neurons d. Autoimmune injury at the neuromuscular junction
ANS: D Myasthenia gravis is a disorder resulting from autoimmune injury at the neuromuscular junction.
A 75-year-old female suffers a stroke and now has difficulty writing and production of language. This condition is most likely caused by occlusion of the: a. Anterior communicating artery b. Posterior communicating artery c. Circle of Willis d. Middle cerebral artery
ANS: D Occlusion of the left middle cerebral artery leads to the inability to find words and difficulty writing.
An older adult is admitted to the ER following a fall. The patient complains of pain in the back. The patient has a history of osteoporosis. The nurse would expect the patient's injury and subsequent pain is most likely due to: a. A fractured hip b. Spinal stenosis c. Herniation of a thoracic disk d. A spinal compression fracture
ANS: D Osteoporosis increases the risk of spinal compression fractures and may be why elderly women report more symptoms than men. A fracture of the hip could have occurred, but the patient's pain is in the back and this would not cause pain in the back. Spinal stenosis is a narrowing of the spinal and is most often congenital and would not be due to a fall. Herniation of a thoracic disk could have occurred, but the most likely explanation is a compression fracture.
A teenage boy sustains a severe closed head injury following an all-terrain vehicle (ATV) accident. He is in a state of deep sleep that requires vigorous stimulation to elicit eye opening. How should the nurse document this in the chart? a. Confusion b. Coma c. Obtundation d. Stupor
ANS: D Stupor is a condition of deep sleep or unresponsiveness from which the person may be aroused or caused to open eyes only by vigorous and repeated stimulation. Confusion is the loss of the ability to think rapidly and clearly and is characterized by impaired judgment and decision making. Coma is a condition in which there is no verbal response to the external environment or to any stimuli; noxious stimuli such as deep pain or suctioning do not yield motor movement. Obtundation is a mild to moderate reduction in arousal (awakeness) with limited response to the environment.
The majority of intervertebral disk herniations occur between which vertebral levels (cervical, C; thoracic, T; lumbar, L; sacral, S)? a. C1 to C3 b. T1 to T4 c. T12 to L3 d. L4 to S1
ANS: D The most common discs affected by herniation are the lumbosacral disks—that is, L5-S1 and L4-L5.
The nursing student would correctly identify the most common symptom of brain abscess as: a. Nuchal rigidity b. Vomiting c. Drowsiness d. Headache
ANS: D The most common symptom of brain abscess is headache.
A 20-year-old male is brought to the emergency room (ER) for treatment of injuries received in a motor vehicle accident. A spinal cord injury is suspected. What two regions should the nurse assess as they are most likely to be damaged? a. Cervical and thoracic regions b. Thoracic and lumbar regions c. Lumbar and sacral regions d. Cervical and lumbar regions
ANS: D Vertebral injuries in adults occur most often at cervical and lumbar regions as these are the most mobile portions of the vertebral column.
A 45-year-old male was previously diagnosed with Parkinson disease. He has impaired fine repetitive motor movements. Which of the following areas is most likely damaged?
Basal ganglia
The region responsible for motor aspects of speech is termed the:
Broca area.
A 12-year-old female presents with hydrocephalus. Blockage of which of the following would cause this condition?
Cerebral aqueduct
A neuron has a resting membrane potential of -70 mV and a threshold of 45 mV. It receives 2 EPSPs that change the membrane potential by 30 mV and 1 IPSP that changes it by 10 mV. Which of the following would occur?
Facilitation
A patient presents with altered respiratory patterns following head trauma. A lesion in which of the following areas would cause these symptoms?
Hindbrain
Which of the following neurons have the capacity for regeneration?
Myelinated peripheral neurons
Which of the following is not a neuroglial cell?
Neuron
The axon leaves the cell body at the:
axon hillock.
If a neuron's membrane potential is held close to the threshold potential by EPSPs, the neuron is said to be:
facilitated.
The convolutions on the surface of the cerebrum are called:
gyri.
Maintenance of homeostasis and instinctive behavioral control arise from the:
hypothalamus.
Characteristics of upper motor neurons include:
influencing and modifying spinal reflex arcs.
Reflex activities concerned with heart rate and blood pressure are controlled by the:
medulla oblongata.
Motor neurons are structurally classified as:
multipolar neurons.
The primary visual cortex is located in the
occipital lobe.
A 32-year-old female suffers from severe brain damage following a motor vehicle accident. After rehabilitation she noticed that her thought processes and goal-oriented behavior were impaired. The area most likely responsible is the:
prefrontal.
Neurotransmitters interact with the postsynaptic membrane by binding to a:
receptor.
