65- Neuro

To evaluate a client's cerebellar function, a nurse should ask:

"Do you have any problems with balance?"

The nurse is preparing a client for a neurological examination by the physician and explains tests the physician will be doing, including the Romberg test. The client asks the purpose of this particular test. The correct reply by the nurse is which of the following?

"It is a test for balance."

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?"

Which of the following neurotransmitters are deficient in myasthenia gravis?

Acetylcholine

Which cranial nerve is tested by listening to a ticking watch?

Acoustic

Which term refers to the inability to coordinate muscle movements, resulting in difficulty walking?

Ataxia

Lesions in the temporal lobe may result in which type of agnosia?

Auditory

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

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

A nurse is working in a neurologist's office. The physician orders a Romberg test. What should the nurse instruct the client to do?

Close eyes and stand erect.

There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected with decreased visual fields.

Cranial nerve 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?

Cranial nerve XII

Which term refers to a method of recording, in graphic form, the electrical activity of a muscle?

Electromyography

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

A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position?

Head of the bed elevated 45 degrees

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

Lateral recumbent, with thighs flexed

A client is admitted to an acute care facility for treatment of a brain tumor. When reviewing the chart, the nurse notes that the client's extremity muscle strength is rated 1/5. Which assessment finding should the nurse anticipate?

Muscle contraction is palpable and visible.

The nursing instructor is talking with her clinical group about the central nervous system. What should the instructor tell the students about the function of the spinal cord?

Serves as a conduit for impulses to and from the brain

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

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

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

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 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

refrain from eating or drinking for now.

Which finding is considered a positive finding of the Romberg test?

Loss of balance

A nurse is noting from a client's neurologic assessment findings that the client's motor impulses are interrupted from the brain to the spinal cord. It also appears that the client lacks sensory impulses from the peripheral sensory neurons to the brain. Which area has the deficit?

Medulla oblongata

Which neurons transmit impulses from the CNS?

Motor

The nurse is caring for a client in the emergency department with a diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the client's face and torso. Which action by the nurse aide would prompt the nurse to provide further instruction?

Moving the client's head to clean behind the ears

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

A nurse is working in an outpatient studies unit administering neurological tests. The client is surprised that paste is used to secure an electroencephalogram and asks how it will be removed from the hair. With what substance does the nurse reply?

Shampoo

Which cerebral lobe contains the auditory receptive areas?

Temporal

The nurse assists the health care provider (HCP) in completing a lumbar puncture (LP). Which should the nurse note as a concern?

The cerebrospinal fluid (CSF) is cloudy in nature.

A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in

Thought content

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

After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an:

evaluation of the corneal reflex response.

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 nurse is caring for a patient who was involved in a motor vehicle accident and sustained a head injury. When assessing deep tendon reflexes (DTR), the nurse observes diminished or hypoactive reflexes. How will the nurse document this finding?

1+

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.

The nurse is assessing the pupils of a patient who has had a head injury. What does the nurse recognize as a parasympathetic effect?

Constricted pupils

A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects in the body systems, what does the nurse anticipate the liver will do?

Convert glycogen to glucose for immediate use.

Which is a sympathetic effect of the nervous system?

Dilated pupils

A patient sustained a head injury during a fall and has changes in personality and affect. What part of the brain does the nurse recognize has been affected in this injury?

Frontal lobe

A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture?

Position the client flat as directed.

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 which cranial nerve?

VIII

The provider orders the Romberg test for a patient. The nurse tells the patient that the provider wants to evaluate his equilibrium by assessing which cranial nerve?

VIII

Lower motor neuron lesions cause

flaccid muscles

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

oculomotor

The spinal cord is composed of 31 pairs of spinal nerves. How many pairs of thoracic nerves are contained within the spinal column?

twelve

Which cerebral lobes is the largest and controls abstract thought?

Frontal

Cranial nerve IX is also known as which of the following?

Glossopharyngeal

Which neurotransmitter demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways?

Serotonin

A 53-year-old man presents to the emergency department with a chief complaint of inability to form words, and numbness and weakness of the right arm and leg. Where would you locate the site of injury?

Left frontoparietal region

If a client has a lower motor neuron lesion, the nurse would expect the client to exhibit

decreased muscle tone

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?

Occipital

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?

cerebral angiography

A patient has a deficiency of the neurotransmitter serotonin. The nurse is aware that this deficiency can lead to:

Depression