Chapter 60 MED SURG

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

"Do you have a problem 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"

Which of the following neurotransmitters are deficient in myasthenia gravis?

Acetylcholine

The nurse is caring for a client with a significant allergy history to various medications and shellfish. Because the client needs to have a diagnostic study with contrast, which medication classification is anticipated?

Antihistamine

What portion of the brain is most likely responsible for the inability to breathe?

Brain stem

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

What part of the brain controls and coordinates muscle movement?

Cerebellum

Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed?

Clonus

The physician orders a Romberg test. What should the nurse instruct the client to do?

Close eyes and stand erect

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.

If a client has a lower motor neuron lesion, the nurse would expect to observe which manifestation upon physical assessment?

Decreased muscle tone

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

Depression

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

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

Lower motor neuron lesions cause

Flaccid

Which anatomic part supplies cerebrospinal fluid to the subarachnoid space and down the spinal cord on the dorsal surface?

Fourth ventricle

Which cerebral lobes is the largest and controls abstract thought?

Frontal

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 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 patient has been diagnosed with a deficiency of the major neurotransmitter acetylcholine. Based on this information, the nurse knows to assess the patient for complications associated with:

Heart rate and rhythm.

. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?

Helicopod

The nurse knows that reflexes in the body are centered where?

In the spinal cord

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

Lateral recumbent, with thighs flexed

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. Administer analgesic medication.

Which neurons transmit impulses from the CNS?

Motor

A patient is admitted to a specialty care unit with a diagnosis of an upper motor neuron lesion. The nurse assesses the patient and documents the presence of:

Muscle spasticity.

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 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

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

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

Twelve

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

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

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

In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve?

XII

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

ataxia

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 nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates:

dysfunction in the brain stem.

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 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. CN IX (glossopharyngeal) CN X (vagus)

During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to:

support the joint where the tendon is being tested.

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

thought content.