Chapter 60: Assessment of Neurologic Function (thepoint)

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

"Do you have any problems with balance?"

A client preparing to undergo a lumbar puncture states he doesn't think he will be able to get comfortable with his knees drawn up to his abdomen and his chin touching his chest. He asks if he can lie on his left side. Which statement is the best response by the nurse? - "Lying on your left side will be fine during the procedure." - "I'll report your concerns to the physician." - "There's no other option but to assume the knee-chest position." - "Although the required position may not be comfortable, it will make the procedure safer and easier to perform."

- "Although the required position may not be comfortable, it will make the procedure safer and easier to perform."

Which term refers to the inability to coordinate muscle movements, resulting in difficulty walking? - Ataxia - Spasticity - Agnosia - Rigidity

- Ataxia

What part of the brain controls and coordinates muscle movement? - Cerebellum - Cerebrum - Midbrain - Brain stem

- Cerebellum

Low levels of the neurotransmitter serotonin lead to which of the following disease processes? - Parkinson's disease - Myasthenia gravis - Depression - Seizures

- Depression

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? - Temporal lobe - Frontal lobe - Parietal lobe - Occipital lobe

- Frontal lobe

A patient is having a lumbar puncture and the physician has removed 20 mL of cerebrospinal fluid. What nursing intervention is a priority after the procedure? - Have the patient lie flat for 1 hour and then sit for 1 hour before ambulating. - Early ambulation - Have the patient lie in a semi-Fowler's position with the head of the bed at 30º. - Have the patient lie flat for 6 hours.

- Have the patient lie flat for 6 hours.

Which cerebral lobe contains the auditory receptive areas? - Frontal - Parietal - Temporal - Occipital

- Temporal

Which of the following neurotransmitters are deficient in myasthenia gravis?

Acetylcholine

The nurse is caring for a male client who is scheduled for a neurologic examination that uses a radiopaque dye. Before the test, the nurse assesses the allergy history of the client and find the client is allergic to seafood. What does the nurse relate the allergy to seafood as?

An allergy to iodine

Lesions in the temporal lobe may result in which type of agnosia? Visual Relationship Tactile Auditory

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 IV CN I CN III CN II

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 III CN IV CN II CN I

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 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? Maintain a basal rate of functioning. Cease function and shunt blood to the heart and lungs. Convert glycogen to glucose for immediate use. Produce a toxic byproduct in relation to stress.

Convert glycogen to glucose for immediate use.

Which is a sympathetic effect of the nervous system? Decreased blood pressure Increased peristalsis Dilated pupils Decreased respiratory rate

Dilated pupils

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? Keep the room brightly lit and play soothing music in the background Encourage the client to drink liberal amounts of fluids Administer antihistamines according to the physician's prescription Help the client take a brisk walk around the testing area

Encourage the client to drink liberal amounts of fluids

Cranial nerve IX is also known as which of the following? - Spinal accessory - Vagus - Hypoglossal - Glossopharyngeal

Glossopharyngeal

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure? Supine, with the knees raised toward the chest Lateral, with right leg flexed Lateral recumbent, with thighs flexed Prone, with the head turned to the right

Lateral recumbent, with thighs flexed

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 temporal region Left frontoparietal region Left basal ganglia Right frontoparietal region

Left frontoparietal region

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? Central Peripheral Sympathetic Parasympathetic

Parasympathetic

A patient had a lumbar puncture 3 days ago in the outpatient clinic and calls the nurse with complaints of a throbbing headache. What can the nurse educate the patient to do for relief of the discomfort? Select all that apply. Take some over-the-counter analgesics. Walk around. Force fluids (unless contraindicated). Limit the amount of fluid to decrease cerebral edema. Get plenty of bed rest.

Take some over-the-counter analgesics. Force fluids (unless contraindicated). Get plenty of bed rest.

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. The pressure is noted to be 90 mm H20. The HCP administers a drug by intrathecal injection. The HCP maintains aseptic procedure.

The cerebrospinal fluid (CSF) is cloudy in nature.

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? XI VI II VIII

VIII

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? VII VIII III X

X

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. use the walker when walking. wear any hearing aids while in the hospital. have their spouse bring in the client's glasses.

refrain from eating or drinking for now.

When learning about the nervous system, students learn that which nervous system regulates the expenditure of energy? - Peripheral - Central - Parasympathetic - Sympathetic

- Sympathetic

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? - IV - V - III - VI

- V

Lower motor neuron lesions cause - flaccid muscles. - no muscle atrophy. - increased muscle tone. - hyperactive and abnormal reflexes.

- flaccid muscles.

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 can repair damage to the spinal cord that occurred with the procedure." - "The blood will replace the cerebral spinal fluid that has leaked out." - "The blood provides moisture at the site, which encourages healing." - "The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid."

- "The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid."

If a client has a lower motor neuron lesion, the nurse would expect to observe which manifestation upon physical assessment? - Muscle spasticity - Hyperactive reflexes - No muscle atrophy - Decreased muscle tone

- Decreased muscle tone

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 - echoencephalography - cerebral angiography - milligram

- cerebral angiography

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: - endocrine system. - sympathetic nervous system. - musculoskeletal system. - parasympathetic nervous system.

- sympathetic nervous system.

A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in - motor ability. - emotional status. - intellectual function. - thought content.

- thought content.

Which of the following areas of the brain are responsible for temperature regulation? - Pons - Thalamus - Hypothalamus - Medulla

- Hypothalamus

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? - Cleaning the neck and upper chest area - Moving the client's head to clean behind the ears - Using mild soapy water to clean the face - Cleaning the eye area from the inner to outer eye

- Moving the client's head to clean behind the ears

A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult that is slowing transmission of the motor neurons, in what would the nurse anticipate a delayed reaction? - Response due to interrupted impulses from the central nervous system - Identification of information due to slowed passages of information to brain. - Processing information transferred from the environment. - Cognitive ability to understand relayed information.

- Response due to interrupted impulses from the central nervous system

A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first? - Obtain two large-bore IV lines. - Obtain a blood sample to evaluate BUN and creatinine concentrations. - Maintain the client NPO for 6 hours before the test. - Assess the client for medication allergies.

- Assess the client for medication allergies.