Chapter 36: introduction to the nervous system prep u

The nurse is admitting a client to the unit who is diagnosed with a lower motor neuron lesion. What entry in the client's electronic record is most consistent with this diagnosis?

"Client demonstrates an absence of deep tendon reflexes."

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

"Do you have any problems with balance?"

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."

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?"

The nurse is scoring the client's level of consciousness using the Glasgow Coma Scale. Which score would indicate that the client is in comatose state?

7

The nurse is completing a neurologic assessment and uses the whisper test to assess which cranial nerve?

Acoustic

A 78-year-old resident of a long-term care facility has left the majority of his supper tray untouched, and the nurse has asked him about the reason for this. The resident states, "For a long time now, food just doesn't taste as well as it used to." The nurse should be aware that the etiology of this problem is most likely to involve:

Age-related changes to the neurological system

The nurse caring for an 80-year-old client knows that the client has a preexisting history of dulled tactile sensation. The nurse should first consider what possible cause for this client's diminished tactile sensation?

Age-related neurologic changes

The nurse is performing a neurologic assessment of a client whose injuries have rendered the client unable to follow verbal commands. How should the nurse proceed with assessing the client's level of consciousness (LOC)?

Assess the client's eye opening and response to stimuli.

A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Of the two illustrations of posturing shown, which demonstrates a more severe dysfunction?

B

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

Constricted pupils

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?

Decorticate

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 vagus nerve

A trauma client in the ICU has been declared brain dead. What diagnostic test is used in making the best determination that the brain's electrical activity has ceased?

Electroencephalography (EEG)

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 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

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

Glossopharyngeal

A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution?

Hot or cold packs

A client in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows the brain regulates body temperature in which of the following areas?

Hypothalamus

A neurological nurse is conducting a focused neurological assessment of a patient who has just been admitted to the rehabilitative facility. During this assessment, the nurse has asked the patient to swallow and has tested the patient's gag reflex with a tongue depressor. These assessments test the function of which of the patient's cranial nerves?

IX (glossopharyngeal) and X (vagus)

The nurse is caring for a client after lumbar puncture. The client reports a severe headache. Which actions should the nurse complete? Select all that apply.

Maintain the client on bed rest; Administer fluids to the client; Position the client in the supine position; Administer analgesic medication

A patient is brought to the emergency room following a motor vehicle accident in which she sustained a head trauma. The patient is complaining of blindness in her left eye. The nurse would be correct in suspecting that this sensory deficit is related to damage in what cerebral lobe?

Occipital

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

Oculomotor

A patient has suffered cerebellar trauma after falling off of a ladder. The patient has been stabilized and is now receiving care on a neurological unit. When planning this patient's care, what nursing diagnosis is most likely to result from an injury to this part of the brain?

Risk for falls

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:

Speech

Which cerebral lobe contains the auditory receptive areas?

Temporal

A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with:

body temperature control

The nurse is caring for a post-lumbar puncture client who is experiencing an intense headache. If the physician chooses aggressive treatment, which nursing action is anticipated?

drawing venous blood to perform a blood patch

The nurse is completing the physical assessment of a client suspected of a neurological disorder. The client reports having recently suffered a head trauma. In such a case, the nurse should:

not move or manipulate the client's head while assessing for bleeding or swelling.

A nurse is completing a neurological assessment and determines that the client has significant visual deficits. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit?

occipital