18 STARRED CRANIAL NERVES
To assess a client's cranial nerve function, a nurse should assess: orientation to person, time, and place. arm drifting. gag reflex. hand grip.
Correct response: gag reflex. Explanation: The gag reflex is governed by the glossopharyngeal nerve, one of the cranial nerves. Hand grip and arm drifting are part of motor function assessment. Orientation is an assessment parameter related to a mental status examination.
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?
V Trigeminal
To help assess a client's cerebral function, a nurse should ask: "Have you noticed a change in your memory?"
"Have you noticed a change in your memory?"
A male patient is scheduled for an EEG. The patient inquires about any diet-related prerequisites that he must take. Which of the following diet-related advice should the nurse provide to the patient?
Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours prior to the test The patient is advised to refrain from taking sedative drugs or drinks that contain caffeine for at least 8 hours prior to the test because these may interfere with the EEG test result. The patient is not advised to increase or decrease the intake of minerals in the diet.
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
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 is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve? CN I CN XII CN VI CN X
CN XII hypoglossal Assessment of the movement of the tongue is cranial nerve XII . Cranial nerve I is the olfactory nerve. Cranial nerve V is the trigeminal nerve responsible for sensation to the face and chewing. Cranial nerve XI is the spinal or accessory nerve responsible for head and shoulder and shoulder movement.
A client presents to the emergency department status postseizure. The physician wants to know what the pressure is in the client's head. What test might be ordered on this client? LUMBAR PUNCTURE IF SUBACRHANOID
Changes in CSF occur in many neurologic disorders. A lumbar puncture (spinal tap) is performed to obtain samples of CSF from the subarachnoid space for laboratory examination and to measure CSF pressure. Echoencephalography records the electrical impulses generated by the brain. Nerve conduction studies measure the speed with which the nerve impulse travels along the peripheral nerve. Electromyography studies the changes in the electrical potential of muscles and the nerves supplying the muscles
Low levels of the neurotransmitter serotonin lead to which of the following disease processes? Myasthenia gravis Depression Seizures Parkinson's disease
Correct response: Depression Explanation: A decrease of serotonin leads to depression. A decrease in the amount of acetylcholine causes myasthenia gravis. Parkinson's disease is caused by a depletion of dopamine. Decreased levels of GABA may cause seizures.
Which cerebral lobes is the largest and controls abstract thought? Occipital Frontal Temporal Parietal
Correct response: Frontal Explanation: The frontal lobe also controls information storage or memory and motor function. The temporal lobe contains the auditory receptive area. The parietal lobe contains the primary sensory cortex, which analyzes sensory information and relays interpretation to the thalamus and other cortical areas. The occipital lobe is responsible for visual interpretation.
A nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm? electroencephalogram cerebral angiography echoencephalography milligram
Correct response: cerebral angiography Explanation: The nurse would anticipate a cerebral angiography, which detects distortion of the cerebral arteries and veins . A milligram detects abnormalities of the spinal canal. An electroencephalogram records electrical impulses of the brain. An echoencephalography is an ultrasound of the structures of the brain.
A high school soccer player sustained five concussions before she was told that she should never play contact sports again. After her last injury, she began experiencing episodes of double vision. She was told that she had most likely incurred damage to which cranial nerve?
VI (Abducens) The abducens cranial nerve supports movement of the eye laterally. Damage to the nerve can cause double vision.
A client is scheduled for standard EEG testing to evaluate a possible seizure disorder. Which nursing intervention should the nurse perform before the procedure? a) Maintain NPO status for 6 hours before the procedure b) Withhold anticonvulsant medications for 24 to 48 hours before the exam c) Sedate the client before the procedure, per orders d) Instruct the client that a standard EEG takes 2 hours
Withholding antiseizure medications for 24 to 48 hours prior to the exam Antiseizure 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 patient 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, the meal is not omitted, because an altered blood glucose level can cause changes in brain wave patterns. The patient is informed that the standard EEG takes 45 to 60 minutes; a sleep EEG requires 12 hours.
The nurse is performing a neurologic assessment on a client diagnosed with a stroke and cannot elicit a gag reflex. This deficit is related to which of the following cranial nerves?
X Vegus
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 Bread Rice Apple
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.
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 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
A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first? Obtain a blood sample to evaluate BUN and creatinine concentrations. Obtain two large-bore IV lines. Assess the client for medication allergies. Maintain the client NPO for 6 hours before the test.
Correct response: Assess the client for medication allergies. Explanation: If a contrast agent is used, the client must be assessed before the CT scan for an iodine/shellfish allergy, because the contrast agent used may be iodine based. If the client has no allergies to shellfish, then kidney function must also be evaluated, as the contrast material is cleared through the kidneys. A suitable IV line for contrast injection and a period of fasting (usually 4 hours) are required before the study. Clients who receive an IV contrast agent are monitored during and after the procedure for allergic reactions and changes in kidney function.
The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve? CN II CN IV CN III CN I
Correct response: CN I Explanation: Cranial nerve (CN) I is the olfactory nerve, which allows the sense of smell. Testing of CN I is done by having the patient identify familiar odors with eyes closed, testing each nostril separately. An inability to smell an odor is a significant finding, indicating dysfunction of this nerve.
Which is a sympathetic effect of the nervous system? Decreased respiratory rate Increased peristalsis Dilated pupils Decreased blood pressure
Correct response: Dilated pupils Explanation: Dilated pupils are a sympathetic effect of the nervous system, whereas constricted pupils are a parasympathetic effect. Decreased blood pressure is a parasympathetic effect, whereas increased blood pressure is a sympathetic effect. Increased peristalsis is a parasympathetic effect, but decreased peristalsis is a sympathetic effect. Decreased respiratory rate is a parasympathetic effect, and increased respiratory rate is a sympathetic effect.
To evaluate a client's cerebellar function, a nurse should ask: "Do you have any problems with balance?" "Have you noticed any changes in your muscle strength?" "Do you have any trouble swallowing food or fluids?" "Do you have any difficulty speaking?"
Correct response: "Do you have any problems with balance?" Explanation: To evaluate cerebellar function, the nurse should ask the client about problems with balance and coordination. The nurse asks about difficulty speaking or swallowing to assess the functions of cranial nerves IX, X, and XII. Questions about muscle strength help her evaluate the client's motor system.
A patient is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the patient has? Dysfunction of the spinal accessory nerve Dysfunction of the facial nerve Dysfunction of the acoustic nerve Dysfunction of the vagus nerve
Correct response: Dysfunction of the vagus nerve Explanation: The vagus nerve (cranial nerve X) controls the gag reflex and is tested by depressing the posterior tongue with a tongue blade. An absent gag reflex is a significant finding, indicating dysfunction of this nerve.
A nurse is completing a neurological assessment and determines that the client has significant visual deficits. A brain tumor is considered. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit? Temporal Parietal Occipital Frontal
Correct response: Occipital Explanation: The vision center is located in the occipital lobe. There is little other functioning that may interfere with the visual process in the other lobes of the brain.
Which of the following terms refer to a method of recording, in graphic form, the electrical activity of the muscle?
Electromyogram is a method of recording, in graphic form, the electrical activity of the muscle. Electroencephalogram 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 safety action will the nurse implement for a client receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)? Check the client's oxygen saturation level using a pulse oximeter after the client has been placed on the MRI table. Note that no special safety actions need to be taken. Ensure that no client care equipment containing metal enters the room where the MRI table is located. Securely fasten the client's portable oxygen tank to the bottom of the MRI table after the client has been positioned on the table.
Correct response: Ensure that no client care equipment containing metal enters the room where the MRI table is located. Explanation: For client safety the nurse must make sure that no client care equipment that contains metal or metal parts (eg, portable oxygen tanks) enters the room where the MRI is located. The client must be assessed for the presence of medication patches with foil backing (e.g., nicotine patch) that may cause a burn. The magnetic field generated by the unit is so strong that any metal-containing items will be strongly attracted and can literally be pulled away with such great force that they can fly like projectiles toward the magnet.
The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly? Gently pressing the bones on the neck Moving the head toward both sides Moving the head and chin toward the chest Lightly tapping the lower portion of the neck to detect sensation
Correct response: Moving the head and chin toward the chest Explanation: The neck is examined for stiffness or abnormal position. The presence of rigidity is assessed by moving the head and chin toward the chest. The nurse should not maneuver the neck if a head or neck injury is suspected or known. The neck should also not be maneuvered if trauma to any part of the body is evident. Moving the head toward the sides or pressing the bones on the neck will not help assess for neck rigidity correctly. While assessing for neck rigidity, sensation at the neck area is not to be assessed.
A patient has been diagnosed with damage to Broca's area of the left frontal lobe. To document the extent of damage, the nurse would assess the patient's: Balance. Hearing. Speech. Vision.
Correct response: Speech. Explanation: The motor strip, which lies in the frontal lobe, anterior to the central sulcus, is responsible for muscle movement. It also contains Broca's area (left frontal lobe region in most people), critical for motor control of speech.
The nurse is completing a neurologic assessment and uses the whisper test to assess which cranial nerve? X Vagus I Olfactory VII Facial VIII Acoustic
Correct response: VIII Acoustic Explanation: Clinical examination of the acoustic nerve can be done by the whisper test. X Vagus Having the client say "ah" tests the vagus nerve. VII Facial Observing for symmetry when the client performs facial movements tests the facial nerve. I Olfactory The olfactory nerve is tested by having the client identify specific odors.
Which cerebral lobe contains the auditory receptive areas? Temporal Parietal Frontal Occipital
Correct response: Temporal Explanation: The temporal lobe plays the most dominant role of any area of the cortex in cerebration. The frontal lobe, the largest lobe, controls concentration, abstract thought, information storage or memory, and motor function. The parietal lobe contains the primary sensory cortex, which analyzes sensory information and relays interpretation to the thalamus and other cortical areas. The occipital lobe is responsible for visual interpretation.
The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of cranial nerve: XI VIII II VI
Correct response: VIII Explanation: There are 12 pairs of cranial nerves. Cranial nerve VIII is the vestibulocochlear or auditory nerve responsible for hearing and balance. Cranial nerve II is the optic nerve. Cranial nerve VI is the abducens nerve responsible for eye movement. Cranial nerve XI is the accessory nerve and is involved with head and shoulder movement.
The nurse is assessing the mental status of a patient. Which of the following questions 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 patient know what day it is, what year it is, and the name of the president of the United States? Is the patient aware of where he or she is? Is the patient aware of who the examiner is and of his or her purpose for being 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 patient's intellectual function. "Are you having hallucinations?" assesses the patient's thought content.
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?
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? Determine whether the client is allergic to iodine, contrast dyes, or shellfish. 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
NEED TO KNOW? A nurse is working in a neurologist's office. The physician orders a Romberg test. The nurse should have the client: touch his or her nose with one finger. close his or her eyes and discriminate between dull and sharp. close his or her eyes and jump on one foot. close his or her eyes and stand erect.
Correct response: close his or her eyes and stand erect. Explanation: In the Romberg test, the client stands erect with the feet close together and eyes closed. If the client sways as if to fall, it is considered a positive Romberg test. All of the other options include components of neurologic tests, indicating neurologic deficits and balance.
During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates: cranial nerves I and II. cranial nerves III and V. cranial nerves VI and VIII. cranial nerves IX and X.
Correct response: cranial nerves IX and X. Explanation: Swallowing is a motor function of cranial nerves IX and X. Cranial nerves I, II, and VIII don't possess motor functions. The motor functions of cranial nerve III include extraocular eye movement, eyelid elevation, and pupil constriction. The motor function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement.
The nurse has completed evaluating the client's cranial nerves. The nurse documents impairment of the right cervical nerves (CN IX and CN X). Based on these findings, the nurse should instruct the client to have their spouse bring in the client's glasses. refrain from eating or drinking for now. wear any hearing aids while in the hospital. use the walker when walking.
Correct response: refrain from eating or drinking for now. Explanation: Significant findings of CN IX (glossopharyngeal) include difficulty swallowing (dysphagia) and impaired taste, and significant findings of CN X (vagus) include weak or absent gag reflex, difficulty swallowing, aspiration, hoarseness, and slurred speech (dysarthria). Based on these findings, the nurse should instruct the client to refrain from eating and drinking and should contact the health care provider. The other instructions are associated with abnormalities of CN II (optic) and CN VIII (acoustic).
