Chapter 65

A trauma patient in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death?

Electroencephalography (EEG)

The nurse is caring for a patient who exhibits abnormal results of the Weber test and Rinne test. The nurse should suspect dysfunction involving what cranial nerve?

Acoustic

The nurse caring for an 80 year-old patient knows that she has a pre-existing history of dulled tactile sensation. The nurse should first consider what possible cause for this patients diminished tactile sensation?

Age-related neurologic changes

A patient exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most plausible cause of this patients health problem?

Cerebellar dysfunction

A nurse is assessing reflexes in a patient with hyperactive reflexes. When the patients foot is abruptly dorsiflexed, it continues to beat two to three times before settling into a resting position. How would the nurse document this finding?

Clonus

A patient is being given a medication that stimulates her parasympathetic system. Following administration of this medication, the nurse should anticipate what effect?

Constricted pupils

The nurse is planning the care of a patient with Parkinsons disease. The nurse should be aware that treatment will focus on what pathophysiological phenomenon?

Decreased availability of dopamine

The physician has ordered a somatosensory evoked responses (SERs) test for a patient for whom the nurse is caring. The nurse is justified in suspecting that this patient may have a history of what type of neurologic disorder?

Demyelinating disease

During the performance of the Romberg test, the nurse observes that the patient sways slightly. What is the nurses most appropriate action?

Document successful completion of the assessment.

A patient is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this patient, the nurse has the patient stick out her tongue and move it back and forth. What is the nurse assessing?

Function of the hypoglossal nerve

The neurologic nurse is testing the function of a patients cerebellum and basal ganglia. What action will most accurately test these structures?

Guide the patient through the performance of rapid, alternating movements.

A nurse is caring for a patient diagnosed with Mnires disease. While completing a neurologic examination on the patient, the nurse assesses cranial nerve VIII. The nurse would be correct in identifying the function of this nerve as what?

Hearing and equilibrium

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 patient in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is which of the following?

Hypothalamus

A patient is having a fight or flight response after receiving bad news about his prognosis. What affect will this have on the patients sympathetic nervous system?

Increase in the secretion of sweat

The nurse has admitted a new patient to the unit. One of the patients admitting orders is for an adrenergic medication. The nurse knows that this medication will have what effect on the circulatory system?

Increased heart rate

The nurse is caring for a patient with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the patients neurologic assessment?

Loss of voluntary control of movement

A patient is scheduled for a myelogram and the nurse explains to the patient that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests?

Lumbar puncture

In the course of a focused neurologic assessment, the nurse is palpating the patients major muscle groups at rest and during passive movement. Data gleaned from this assessment will allow the nurse to describe which of the following aspects of neurologic function?

Muscle tone

When caring for a patient with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would the nurse use to elicit a response from cranial nerve VII?

Observe for facial movement symmetry, such as a smile

A patient is brought to the ER following a motor vehicle accident in which he sustained head trauma. Preliminary assessment reveals a vision deficit in the patients left eye. The nurse should associate this abnormal finding with trauma to which of the following cerebral lobes?

Occipital

The nurse is doing an initial assessment on a patient newly admitted to the unit with a diagnosis of cerebrovascular accident (CVA). The patient has difficulty copying a figure that the nurse has drawn and is diagnosed with visual-receptive aphasia. What brain region is primarily involved in this deficit?

Parietal-occipital area

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

Patient demonstrates an absence of deep tendon reflexes.

What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brains surface?

Pia mater

The patient in the ED has just had a diagnostic lumbar puncture. To reduce the incidence of a post- lumbar puncture headache, what is the nurses most appropriate action?

Position the patient prone.

A patient with lower back pain is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should prioritize what action?

Positioning the patient with the head of the bed elevated 45 degrees

A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age- related changes. Of what phenomenon should the nurse be aware?

Reduction in cerebral blood flow

A patient scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the patient for the MRI should prioritize which of the following actions?

Removing all metal-containing objects

A trauma patient was admitted to the ICU with a brain injury. The patient had a change in level of consciousness, increased vital signs, and became diaphoretic and agitated. The nurse should recognize which of the following syndromes as the most plausible cause of these symptoms?

Sympathetic storm

The nursing students are learning how to assess function of cranial nerve VIII. To assess the function of cranial nerve VIII the students would be correct in completing which of the following assessment techniques?

Test for air and bone conduction (Rinne test).

A patient is currently being stimulated by the parasympathetic nervous system. What effect will this nervous stimulation have on the patients bladder?

The parasympathetic nervous system makes the bladder contract.

A patient for whom the nurse is caring has positron emission tomography (PET) scheduled. In preparation, what should the nurse explain to the patient?

The test may result in dizziness or lightheadedness.

A 72-year-old man has been brought to his primary care provider by his daughter, who claims that he has been experiencing uncharacteristic lapses in memory. What principle should underlie the nurses assessment and management of this patient?

Thorough assessment is necessary because changes in cognition are always considered to be pathologic.

Assessment is crucial to the care of patients with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply.

Understanding of the tests used to diagnose neurologic disorders Knowledge of nursing interventions related to assessment and diagnostic testing Knowledge of the anatomy of the nervous system

The nurse educator is reviewing the assessment of cranial nerves. What should the educator identify as the specific instances when cranial nerves should be assessed? Select all that apply.

When level of consciousness is decreased With brain stem pathology In the presence of peripheral nervous system disease

A patient had a lumbar puncture performed at the outpatient clinic and the nurse has phoned the patient and family that evening. What does this phone call enable the nurse to determine?

Whether the patient has had any complications of the test

A patient is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the patient in preparation for this test?

You will need to lie still throughout the procedure.

An elderly patient is being discharged home. The patient lives alone and has atrophy of his olfactory organs. The nurse tells the patients family that it is essential that the patient have what installed in the home?

A smoke detector

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

Assess the patients eye opening and response to stimuli.

The nurse is conducting a focused neurologic assessment. When assessing the patients cranial nerve function, the nurse would include which of the following assessments?

Assessment of gag reflex