Chapter 65: Assessment of Neurologic Function

14) A patient exhibiting an uncoordinated gait has presented at the clinic. The nurse knows that what brain structure has the function of balance and coordination? A) Cerebellum B) Pons C) Medulla D) Midbrain

ANS: A Cerebellum The cerebellum controls fine movement, balance, position sense, and integration of sensory input. Portions of the pons control the heart, respiration, and blood pressure. Cranial nerves IX through XII connect to the brain in the medulla. Cranial nerves III and IV originate in the midbrain.

16) A patient is being given a medication that stimulates her parasympathetic system. What is an effect of parasympathetic stimulation? A) Constricted pupils B) Dilated bronchioles C) Decreased peristaltic movement D) Relaxed muscular walls of the urinary bladder

ANS: A Constricted pupils Parasympathetic stimulation results in constricted pupils, constricted bronchioles, increased peristaltic movement, and contracted muscular walls of the urinary bladder.

22) A patient is admitted to your unit with an exacerbation of multiple sclerosis. When assessing this patient you have the patient stick out the tongue and move it back and forth. What are you assessing? A) Damage to the hypoglossal nerve B) Damage to the vagus nerve C) Damage to the spinal nerve D) Damage to the trochlear nerve

ANS: A Damage to the hypoglossal nerve The hypoglossal nerve is the 12th cranial nerve. It is responsible for movement of the tongue. This makes options B, C, and D incorrect.

17) A patient with lower back pain is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the patient in which position? A) Head of the bed elevated 45 degrees B) Prone C) Supine with his feet raised D) Supine with his head lower than his trunk

ANS: A Head of the bed elevated 45 degrees After a myelogram, positioning will depend on the dye injected. When a water-soluble dye such as metrizamide is injected, the head of the bed is elevated to a 45-degree angle to slow the upward dispersion of the dye. The other positions are contraindicated when a water-soluble contrast dye is used. If an air-contrast study was performed, the patient should be positioned supine with his head lower than his trunk.

29) A public health nurse has been asked to give an educational presentation on aging to the senior citizens at the senior citizens center. The nurse would include in her presentation information on sensory losses due to aging. Since reaction to painful stimuli is an important warning signal, what must be used with caution when treating the elderly? A) Hot or cold packs B) Analgesics C) Anti-inflammatory medications D) Whirlpool baths

ANS: A Hot or cold packs Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used. The older patient may be burned or suffer frostbite before being aware of any discomfort. Any medication is used with caution in the elderly, but not because of the decreased sense of heat or cold. Whirlpool baths are generally not a routine treatment ordered for the elderly.

33) A patient is scheduled for a myelogram. The nurse explains to the patient that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse knows that the preparation is similar to which of the following neurological tests? A) Lumbar puncture B) Magnetic resonance imaging (MRI) C) Cerebral angiography D) Electroencephalography (EEG)

ANS: A Lumbar puncture A myelogram is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. Patient preparation for a myelogram would be similar to that for lumbar puncture (Refer to Chart 60-03).

11) The patient in the emergency department has just had a diagnostic lumbar puncture. To reduce the incidence of a post-lumbar puncture headache, the nurse suggests what position for 3 hours after the procedure? A) Prone B) Supine, head of bed flat C) Flat, in a side-lying position D) Side-lying with the head of bed elevated 30 degrees

ANS: A Prone The lumbar puncture headache may be avoided if a small-gauge needle is used and if the patient remains prone after the procedure. When a large volume of fluid is removed, the patient is positioned prone for 2 hours, then flat in a side-lying position for 2 to 3 hours, and then supine and prone for 6 or more hours.

21) A patient with Parkinson's disease is being cared for on your unit. The nurse would be correct in identifying what neurotransmitter as being decreased in this disease? A) Acetylcholine B) Dopamine C) Neurontin D) Serotonin

ANS: B Dopamine Parkinson's disease develops from decreased availability of dopamine, while acetylcholine binding to muscle cells is impaired in myasthenia gravis. Therefore options A, C, and D are incorrect.

30) A trauma patient in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death? A) Magnetic resonance imaging (MRI) B) Electroencephalography (EEG) C) Electromyelography (EMG) D) Computed tomography (CT)

ANS: B EEG The EEG can be used in determining brain death. MRI, CT, and EMG are not normally used in determining brain death.

4) The nurse has admitted a new patient to the unit. One of the patient's admitting orders is for an adrenergic medication. The nurse knows that this medication will have what effect on the circulatory system? A) Thin, watery saliva B) Increased heart rate C) Decreased blood pressure D) Constricted bronchioles

ANS: B Increased heart rate The term "adrenergic" refers to the sympathetic nervous system. Sympathetic effects include an increased rate and force of the heartbeat. Cholinergic effects, which correspond to the parasympathetic division of the autonomic nervous system, include thin, watery saliva, decreased rate and force of heartbeat, and decreased blood pressure. Refer to Table 60-03.

1) A client is brought to the emergency room following a motor vehicle accident in which he sustained head trauma. The patient is complaining of blindness in the left eye. The nurse would be correct in documenting this abnormal finding as corresponding to which of the following cerebral lobes? A) Temporal B) Occipital C) Parietal D) Frontal

ANS: B Occipital The posterior lobe of the cerebral hemisphere is responsible for visual interpretation. The temporal lobe contains the auditory receptive areas. The parietal lobe contains the primary sensory cortex, and is essential to an individual's awareness of the body in space, as well as orientation in space and spatial relations. The frontal lobe functions in concentration, abstract thought, information storage or memory, and motor function.

3) A nursing instructor is talking with her nursing students about aging and neurological changes. What would the instructor tell the students is a normal neurological change in the aging process? A) Hyperactive deep tendon reflexes B) Reduction in cerebral blood flow (CBF) C) Increased cerebral metabolism D) Hypersensitivity to painful stimuli

ANS: B Reduction in cerebral blood flow (CBF) Reduction in cerebral blood flow (CBF) is a change that occurs in the normal aging process. Deep tendon reflexes can be decreased or in some cases absent. Cerebral metabolism decreases as the patient advances in age. Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used.

2) A patient scheduled for a Magnetic Resonance Imaging (MRI) has arrived at the radiology department. The nurse who prepares the patient for the MRI would be sure to include what? A) Withholding stimulants 24 to 48 hours prior to exam. B) Removing all metal-containing objects. C) Instructing patient to void prior to exam. D) Initiating an intravenous line for administration of contrast.2)

ANS: B Removing all metal-containing objects. Patient preparation for an MRI consists of removing all metal-containing objects prior to the exam. Withholding stimulants would not affect an MRI, this relates to an electroencephalography (EEG). Instructing the patient to void is patient preparation for a lumbar puncture. Initiating an intravenous line for administration of contrast would be done if the patient was having a CT scan with contrast.

6) The nurse is doing an initial assessment on a client t newly admitted to the unit with a diagnosis of cerebrovascular accident (CVA). The client has difficulty copying a figure that the nurse has drawn. The nurse uses this technique to assess for what type of aphasia? A) Auditory-receptive B) Visual-receptive C) Expressive speaking D) Expressive writing

ANS: B Visual-receptive Difficulty copying a figure that the nurse has drawn would be considered visual-receptive aphasia. Expressive aphasia is the inability to express oneself, and is often associated with damage to the left frontal lobe area. Receptive aphasia is the inability to understand what someone else is saying, and is often associated with damage to the temporal lobe area.

24) Assessment is crucial to the care of patients with neurological dysfunction. What does assessment require? (Mark all that apply.) A) The ability to select mediations for the neurologic dysfunction B) Understanding of the tests used to diagnose neurological disorders C) Knowledge of nursing interventions related to assessment and diagnostic testing D) Knowledge of the anatomy of the nervous system E) Knowledge of nursing diagnosis

ANS: B, C, D B) Understanding of the tests used to diagnose neurological disorders, C) Knowledge of nursing interventions related to assessment and diagnostic testing, D) Knowledge of the anatomy of the nervous system Assessment requires knowledge of the anatomy and physiology of the nervous system and an understanding of the array of tests and procedures used to diagnose neurologic disorders. Knowledge about the nursing implications and interventions related to assessment and diagnostic testing is also essential.

19) The nursing instructor is talking with her students about the assessment of cranial nerves. What would the instructor tell her students about the specific instances when cranial nerves should be assessed? (Mark all that apply.) A) When a neurogenic bladder develops B) When level of consciousness is decreased C) With brainstem pathology D) In the presence of peripheral nervous system disease E) When a spinal reflex is interrupted

ANS: B, C, D B) When level of consciousness is decreased, C) With brainstem pathology, D) In the presence of peripheral nervous system disease Cranial nerves are assessed when level of consciousness is decreased, with brainstem pathology, or in the presence of peripheral nervous system disease. Abnormalities in muscle tone and the noting of involuntary movements are not cause to assess cranial nerves.

23) A trauma patient was admitted to the ICU with a brain injury. The patient had a change in level of consciousness, along with a change in vital signs, and became diaphoretic and agitated. The nurse would know that the patient is having what? A) Aadrenal crisis B) A hypothalamic collapse C) A sympathetic storm D) A Cranial nerve deficit

ANS: C A sympathetic storm Sympathetic storm is a syndrome associated with changes in level of consciousness, altered vital signs, diaphoresis, and agitation that may result from hypothalamic stimulation of the sympathetic nervous system following traumatic brain injury. Options A, B, and D are incorrect.

27) A 78-year-old male patient has been admitted to your unit with neurological deficits of unknown origin. The nurse caring for this patient knows that dulled tactile sensation in this patient is a normal finding. What could this dulled tactile sensation cause? A) Damage to cranial nerve VIII B) Adverse medication effects C) Age-related neurologic changes D) An undiagnosed cerebrovascular accident in early adulthood

ANS: C Age-related neurologic changes Tactile sensation is dulled in the elderly person due to a decrease in the number of sensory receptors. While thorough assessment is necessary, it is possible that this change is unrelated to pathophysiological processes.

5) A nurse is assessing reflexes in a patient with hyperactive reflexes. When the patient's foot is abruptly dorsiflexed, it continues to "beat" two to three times before setting into a resting position. How would the nurse document this finding? A) Rigidity B) Flaccidity C) Clonus D) Ataxia

ANS: C Clonus When reflexes are very hyperactive, a phenomenon called clonus may be elicited. If the foot is abruptly dorsiflexed, it may continue to "beat" two to three times before it settles into a position of rest. Rigidity is an increase in muscle tone at rest characterized by increased resistance to passive stretch. Flaccidity is lack of muscle tone. Ataxia is the inability to coordinate muscle movements, resulting in difficulty walking, talking, and performing self-care activities.

20) A patient in the operating room 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? A) Cerebellum B) Thalamus C) Hypothalamus D) Midbrain

ANS: C Hypothalamus The hypothalamus plays an important role in the endocrine system because it regulates the pituitary secretion of hormones that influence metabolism, reproduction, stress response, and urine production. It works with the pituitary to maintain fluid balance through hormonal release and maintains temperature regulation by promoting vasoconstriction or vasodilatation. In addition, the hypothalamus is the site of the hunger center and is involved in appetite control. That makes options A, B, and D incorrect.

18) A patient is having a "fight or flight response" after a disagreement with a family member. What affect will this have on the sympathetic nervous system? A) Constriction of blood vessels in the heart muscle B) Constriction of bronchioles C) Increase in the secretion of sweat D) Constriction of pupils

ANS: C Increase in the secretion of sweat Sympathetic nervous system stimulation results in dilated blood vessels in the heart and skeletal muscle, dilated bronchioles, increased secretion of sweat, and dilated pupils.

8) You are caring for a patient with an upper motor neuron lesion. What clinical manifestations would you expect this patient to exhibit? A) Decreased muscle tone B) Flaccid paralysis C) Loss of voluntary control D) Slow reflexes

ANS: C Loss of voluntary control Upper motor neuron lesions do not cause muscle atrophy, flaccid paralysis, or slow reflexes. Upper motor neuron lesions do cause loss of voluntary control.

25) When caring for a patient with 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? A) Palpate trapezius muscle while patient shrugs should against resistance. B) Administer the whisper or watch-tick test. C) Observe for symmetry of facial movements, such as a smile. D) Note any hoarseness in the patient's voice.

ANS: C Observe for symmetry of facial movements, such as a smile Cranial nerve VII is the facial nerve. An appropriate assessment technique for this cranial nerve would include observing for symmetry while the patient performs facial movements: smiles, whistles, elevates eyebrows, and frowns. Palpating and noting strength of the trapezius muscle while the patient shrugs shoulders against resistance would be completed to assess cranial nerve XI (spinal accessory). Assessing cranial nerve VIII (acoustic) would involve using the whisper or watch-tick test to evaluate hearing. Noting any hoarseness in the patient's voice would involve assessment of cranial nerve X (vagus). Refer to Chart 60-01.

31) Your patient is scheduled for computed tomography (CT) scanning of the brain because of neurologic deficits. What would you tell your patient in preparation for this test? A) No metal objects can enter the procedure room. B) You need to fast for 8 hours prior to the test. C) You will need to lie still throughout the procedure. D) There will be a lot of noise during the test.

ANS: C You will need to lie still throughout the procedure Preparation includes teaching the patient about the need to lie quietly throughout the procedure. If the patient were having an MRI, options A and D would be appropriate teaching topics. Option B is incorrect because there is no need to fast prior to a CT scan of the brain.

10) An elderly patient is being discharged home. The patient lives alone and has atrophy of his olfactory organs. The nurse tells the patient's family that it is essential that the patient have what installed in the home? A) Grab bars B) Nonslip mats C) Baseboard heaters D) A smoke detector

ANS: D A smoke detector The sense of smell deteriorates with age. The olfactory organs are responsible for smell. This may present a safety hazard for the patient because he or she may not smell smoke or gas leaks. A smoke and carbon monoxide detector should be installed.

9) The nurse is admitting a patient to the unit who is diagnosed with a lower motor neuron lesion. What clinical manifestations would you expect this patient to exhibit? A) Increased muscle tone B) No muscle atrophy C) Hyperactive and abnormal reflexes D) Absent or decreased reflexes

ANS: D Absent or decreased reflexes Lower motor neuron lesions cause flaccid muscle paralysis, muscle atrophy, decreased muscle tone, and loss of voluntary control.

12) The nursing instructor is teaching the beginning nursing students how to assess a patient's cranial nerve function. The instructor would teach the students to do what? A) Assess hand grip. B) Assess orientation to person, time, and place. C) Assess arm drifting. D) Assess gag reflex.

ANS: D Assess gag reflex. The gag reflex is governed by the glossopharyngeal nerve, one of the cranial nerves. Hand grip and arm drifting are part of motor function assessment. Orientation is an assessment parameter related to a mental status examination.

13) A nurse is caring for a patient diagnosed with Ménière's disease. While completing a neurological exam on the patient the nurse assesses cranial nerve VIII. The nurse would be correct in identifying the function of this nerve as what? A) Movement of the tongue B) Visual acuity C) Sense of smell D) Hearing and equilibrium

ANS: D Hearing and equilibrium Cranial nerve VIII (acoustic) is responsible for hearing and equilibrium. Cranial nerve XII (hypoglossal) is responsible for movement of the tongue. Cranial nerve II (optic) is responsible for visual acuity and visual fields. Cranial nerve I (olfactory ) functions in sense of smell. Refer to Table 60-02.

7) What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brain's surface? A) Dura mater B) Arachnoid C) Fascia D) Pia mater

ANS: D Pia mater The term "meninges" describes the fibrous connective tissue that covers the brain and spinal cord. The meninges have three layers, the dura mater, arachnoid, and pia mater. The pia mater is the innermost membrane that hugs the brain closely and extends into every fold of the brain's surface. The dura mater is the outermost layer and covers the brain and spinal cord. The arachnoid is the middle membrane and is responsible for the production of cerespinal fluid.

15) 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? A) Have the patient identify familiar odors with the eyes closed B) Assess papillary reflex C) Utilize the Snellen chart D) Test for air and bone conduction (Rinne)

ANS: D Test for air and bone conduction (Rinne) Cranial nerve VIII is the acoustic nerve. It functions in hearing and equilibrium. When assessing this nerve the nurse would test for air and bone conduction (Rinne) with a tuning fork. Assessment of papillary reflex would be completed for cranial nerves III (oculomotor), IV (trochlear), and VI (abducens). The Snellen chart would be used to assess cranial nerve II (optic).

36) A patient is currently being stimulated by the parasympathetic nervous system. What effect will this nervous stimulation have on the patients bladder? A) The parasympathetic nervous system causes urinary retention. B) The parasympathetic nervous system causes bladder spasms. C) The parasympathetic nervous system causes urge incontinence. D) The parasympathetic nervous system makes the bladder contract.

ANS: D The parasympathetic nervous system makes the bladder contract. The parasympathetic division of the nervous system causes contraction (stimulation) of the urinary bladder muscles and a decrease (inhibition) in heart rate, whereas the sympathetic division produces relaxation (inhibition) of the urinary bladder and an increase (stimulation) in the rate and force of the heartbeat.

32) A patient you are caring for has a positron emission tomography (PET) scheduled. You are preparing the patient for the test. What would be important to explain to your patient? A) The test will temporarily limit blood flow through the brain. B) An allergy to iodine precludes getting the radio-opaque dye. C) The patient will need to endure loud noises during the test. D) The test may result in dizziness or lightheadedness.

ANS: D The test may result in dizziness or lightheadedness. Key nursing interventions include patient preparation, which involves explaining the test and teaching the patient about inhalation techniques and the sensations (eg, dizziness, light-headedness, and headache) that may occur. A PET scan does not show the blood flow through the brain. An allergy to iodine precludes you from getting the dye for an MRI, and the loud noise is heard in an MRI.

28) 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? A) Loss of short-term memory is normal in older adults, but loss of long-term memory is pathologic. B) Lapses in memory in older adults are considered benign unless they have negative consequences. C) Gradual increases in confusion accompany the aging process. D) Thorough assessment is necessary because changes in cognition are always considered to be pathologic.

ANS: D Thorough assessment is necessary because changes in cognition are always considered to be pathologic. Although mental processing time decreases with age, memory, language, and judgment capacities remain intact. Change in mental status should never be assumed to be a normal part of aging.

26) 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? A) Trigeminal B) Acoustic C) Hypoglossal D) Trochlear26

Ans: B Acoustic Abnormal hearing can correlate with damage to cranial nerve VIII (acoustic). The acoustic nerve functions in hearing and equilibrium. The trigeminal nerve functions in facial sensation, corneal reflex, and chewing. The hypoglossal nerve moves the tongue. The trochlear nerve controls muscles that move the eye.

37) 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)? A) Assess the patients vital signs and correlate these with the patients baselines. B) Assess the patients eye opening and response to stimuli. C) Document that the patient currently lacks a level of consciousness. D) Facilitate diagnostic testing in an effort to obtain objective data.

Ans: B Assess the patients eye opening and response to stimuli. If the patient is not alert or able to follow commands, the examiner observes for eye opening; verbal response and motor response to stimuli, if any; and the type of stimuli needed to obtain a response. Vital signs and diagnostic testing are appropriate, but neither will allow the nurse to gauge the patients LOC. Inability to follow commands does not necessarily denote an absolute lack of consciousness.

34) 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? A) Hypothalamic disorder B) Demyelinating disease C) Brainstem deficit D) Diabetic neuropathy

Ans: B Demyelinating disease SERs are used to detect deficits in the spinal cord or peripheral nerve conduction and to monitor spinal cord function during surgical procedures. The test is also useful in the diagnosis of demyelinating diseases, such as multiple sclerosis and polyneuropathies, where nerve conduction is slowed. The test is not done to diagnose hypothalamic disorders, brainstem deficits, or diabetic neuropathies.

38) 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? A) Muscle dexterity B) Muscle tone C) Motor symmetry D) Deep tendon reflexes

Ans: B Muscle tone Muscle tone (the tension present in a muscle at rest) is evaluated by palpating various muscle groups at rest and during passive movement. Data from this assessment do not allow the nurse to ascertain the patients dexterity, reflexes, or motor symmetry.

40) During the performance of the Romberg test, the nurse observes that the patient sways slightly. What is the nurses most appropriate action? A) Facilitate a referral to a neurologist. B) Reposition the patient supine to ensure safety. C) Document successful completion of the assessment. D) Follow up by having the patient perform the Rinne test.

Ans: C Document successful completion of the assessment. Slight swaying during the Romberg test is normal, but a loss of balance is abnormal and is considered a positive Romberg test. Slight swaying is not a significant threat to the patients safety. The Rinne test assesses hearing, not balance.

35) 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? A) What are the patients and family's expectations of the test B) Whether the patients family had any questions about why the test was necessary C) Whether the patient has had any complications of the test D) Whether the patient understood accurately why the test was done

Ans: C Whether the patient has had any complications of the test Contacting the patient and family after diagnostic testing enables the nurse to determine whether they have any questions about the procedure or whether the patient had any untoward results. The other listed information should have been elicited from the patient and family prior to the test.

39) The neurologic nurse is testing the function of a patients cerebellum and basal ganglia. What action will most accurately test these structures? A) Have the patient identify the location of a cotton swab on his or her skin with the eyes closed. B) Elicit the patients response to a hypothetical problem. C) Ask the patient to close his or her eyes and discern between hot and cold stimuli. D) Guide the patient through the performance of rapid, alternating movements.

Ans: D Guide the patient through the performance of rapid, alternating movements Cerebellar and basal ganglia influence on the motor system is reflected in balance control and coordination. Coordination in the hands and upper extremities is tested by having the patient perform rapid, alternating movements and point-to-point testing. The cerebellum and basal ganglia do not mediate cutaneous sensation or judgment.