Chapter 20-Nervous system (PREPU)

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What instruction should a nurse give a client when having trouble eliciting a response from testing the patellar deep tendon reflex?

"Place your hands together, lock your fingers, and squeeze."

How many pairs of cranial nerves exit from the brain?

12

A nursing instructor is describing the peripheral nervous system to a group of students. The instructor would explain that there are how many pairs of spinal nerves?

31

The nurse has asked the client to stand for 30 seconds with his arms forward, palms up, and eyes closed. The client pronates (turns downward) his left palm during the test. What health problem should the nurse first suspect in light of this assessment finding?

A lesion in the corticospinal tract

The nurse lightly strokes the sides of a client's abdomen, above and below the umbilicus. For which reflex is the nurse testing?

Abdominal

What should the nurse assess to test the function of the occipital lobe?

Ability to read

A 7-year-old boy is performing poorly in school. His teacher is frustrated because he is frequently seen "staring off into space" and not paying attention. If this is a seizure, it most likely represents which type?

Absence This is a common description and scenario for absence seizures, which are generally brief (fewer than 10 seconds, "petit mal"). They generally occur without warning and do not have a post-ictal confused state. Pseudoseizures are difficult to diagnose but generally involve dramatic-appearing movements, similar to tonic-clonic seizures. Myoclonus represents a single brief jerk of the trunk and limbs.

Which of the following is usually the first sign of neurological deterioration?

Altered mentation and decreasing level of consciousness

A nurse is preparing to assess a client's cerebellar function. What aspect of neurological function should the nurse address?

Balance

the nurse has positioned a client supine and asked her to perform the heel-to-shin test. An inability to run each heel smoothly down each shin should prompt the nurse to perform further assessment in what domain?

Balance and coordination

A nurse cares for a client who suffered a cerebrovascular accident and demonstrates the inability to speak clearly. The nurse recognizes that injury has occurred to what portion of the brain?

Broca's area The Broca's area is the center that is responsible for speech. The temporal lobe helps with receiving and interpreting impulses from the ear. The occipital lobe influences the ability to read with understanding and is the primary visual receptor center. The medulla oblongata contains the nuclei for the cranial nerves and has centers that control and regulate respiratory function, heart rate and force, and blood pressure.

The brain is a network of interconnecting neurons that control and integrate the body's activities. What components make up these neurons? Select all that apply.

Cell body Axon Dendrite

A nurse observes a client's gait and notes it to be wide-based and staggering. The Romberg test results were positive. The nurse recognizes this as what type of abnormal gait?

Cerebellar ataxia

During the Romberg test, a client is unable to stand with his feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would identify this as which of the following?

Cerebellar ataxia A wide-based, staggering, unsteady gait and positive Romberg test (client unable to stand with feet together) suggest cerebellar ataxia. Spastic hemiparesis is characterized by a flexed arm held close to the body while the client drags the toes of the leg or circles it stiffly outward and forward. A Parkinsonian gait is a shuffling gait. A scissors gait is a short stiff gait with the thighs overlapping each other with each step.

The nurse walks into a client's room and finds that the client is disoriented to time and place but is awake and responsive. What term best describes this client?

Confused

A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment?

Coordination The cerebellum's primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone. Therefore, a priority assessment area would be coordination. The other options listed are distracters.

The nurse is assessing a 51-year-old morbidly obese client who is seeking care for the recent loss of sensation in his feet and toes. The client also complains of intermittent burning and tingling in his feet that radiate up his legs. For which of the following health problems should the nurse first assess?

Diabetic peripheral neuropathy

What would the nurse most likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident?

Difficulty speaking The frontal lobe contains Broca's area, which is responsible for speech. Injury to this area may lead to difficulty speaking. Difficulty with sounds would be associated with the temporal lobe. Loss of tactile sensation would be associated with the parietal lobe. Blurred vision would be associated with the occipital lobe.

The nurse has assessed pupil size in a newly admitted client on the neuro-trauma unit. The client's pupils are unequal in size, and the healthcare provider is notified. The nurse is instructed that the findings indicate physiological anisocoria based on the healthcare provider's knowledge of the client's history. What is the nurse's best action?

Document the findings and healthcare provider's response.

Upon reviewing the client's medical record, the nurse finds the client has left ptosis. The nurse would assess the client for what?

Drooping of the left eye Ptosis is drooping of the eye lid. Swelling of the optic nerve is papilledema. A loss visual fields may be associated with retinal detachment or damage.

When preparing to test a client for meningeal irritation, what would the nurse to do first?

Ensure no injury to the cervical spine Before testing a client for meningeal irritation, the nurse needs to ensure that there is no injury to cervical vertebrae or the cervical cord. Otherwise further injury could occur because testing involves flexing the neck. It is not necessary to check for fever or chills or a Babinski reflex. The client is positioned supine for these tests

During assessment, the nurse notes the client has limited movement of his lower extremities and sways when standing with feet together. The nurse identifies that the client is at risk for what?

Falls The client is at risk for falls due to impaired mobility and decreased movement of his lower extremities. There is no evidence to support the client is at risk for a stroke or pressure ulcers.

True or False After testing deep tendon reflexes, the nurse documents 2+. The nurse should evaluate further.

False

A client who was injured by a fall at a construction site has been admitted to the hospital. He has suffered nerve damage such that his gag reflex is no longer intact, requiring him to receive intravenous total parenteral nutrition. Which nerve should the nurse suspect to be involved in this client's injury?

Glossopharyngeal (IX) The glossopharyngeal nerve (cranial nerve IX) contains sensory fibers for taste on posterior third of tongue and sensory fibers of the pharynx that result in the "gag reflex" when stimulated.

The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on possibly omitting from the exam?

Hop on one foot

Which part of the brain controls the vital functions of temperature, heart rate, blood pressure, sleep, the anterior and posterior pituitary, the autonomic nervous system, and emotions and maintains overall autonomic control?

Hypothalamus

What should the nurse assess to test the function of the temporal lobe?

Impulses from the ear

A client has presented with signs and symptoms that are suggestive of Bell's palsy. What assessment finding is most consistent with this diagnosis?

Inability to wrinkle the forehead

Which of the following would lead the nurse to suspect meningeal irritation?

Pain and flexion of the hips and knees with neck flexion

Examination of a client's gait reveals that the client is stooped over when walking and that he slowly shuffles. As well, the client maintains a stiff posture when walking. The nurse should document what type of gait?

Parkinsonian gait

A client complains of headaches each morning that resolve after getting out of bed. What would be most appropriate for the nurse to do?

Refer the client for immediate medical follow-up.

The nurse documents "Romberg test positive" on a client's medical record. What did the nurse most likely assess in this client?

Swaying

A nurse is working with a client who is victim of a shooting. The client has an increased pulse rate and pupil dilation and is clearly in stress. The nurse recognizes the "fight-or-flight" response in this client and understands that this represents an activation of which of the following?

Sympathetic nervous system

Which of the following assessments is most likely to provide insight into the function of the client's CN VIII?

Test the client's hearing for lateralization and bone and air conduction.

The nurse is performing the Romberg test as part of a client's focused neurological assessment. What finding would constitute a positive Romberg test?

The client moves her feet apart to prevent herself from falling.

Which tests are appropriate for a nurse to perform to test cranial nerve VIII?

Whisper, Rinne, and Weber tests

Which assessment procedure should a nurse institute to test a client for stereognosis?

With eyes closed, ask the client to identify a familiar object that is placed in their hand

Which of the following assessment techniques should the nurse use to determine a client's stereognosis?

With the client's eyes closed, place a coin or key in hand and ask him or her to identify the object.

A client is concerned about tripping when walking and feeling uncoordinated. Which part of the brain might be causing this client's symptoms?

cerebellum The cerebellum lies at the base of the brain, coordinates all movements and helps maintain the body upright in space. The brainstem regulates respiratory and cardiac function and includes the reticular activating system (RAS), and the midbrain, pons, and medulla oblongata. The frontal lobe is responsible for higher intellectual function, speech production, and ipsilateral motor control. The parietal lobe is the primary somatic sensory area.

The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the

glossopharyngeal.

A client is in the emergency room with what could be a lumbar injury. Which deep tendon reflex would be most appropriate to test?

patellar

What task should a nurse ask a client to perform to assess the function of cranial nerve XI?

shrug shoulders against resistance The function of cranial nerve XI can be assessed by asking the client to shrug his or her shoulders against resistance. Asking the client to move the tongue from side to side assesses function of the hypoglossal nerve, Cranial nerve XII. The nurse asks the client to swallow water to assess the function of cranial nerves IX and X. Asking the client to walk in heel-to-toe fashion helps in assessment of balance.

The Glasgow Coma Scale measures the level of consciousness in clients who are at high risk for rapid deterioration of the nervous system. A score of 13 indicates

some impairment.

The diencephalon of the brain consists of the

thalamus and hypothalamus


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