nerv 1
7. Which neurons transmit impulses from the CNS? A) Sensory B) Neurilemma C) Dendrites D) Motor
Ans: D Feedback: Neurons are either sensory or motor. Sensory neurons transmit impulses to the CNS; motor neurons transmit impulses from the CNS. A membranous sheath called the neurilemma covers the myelin of axons in peripheral nerves. Dendrites are threadlike projections or fibers.
22. Which diagnostic procedure would the nurse anticipate first if the goal was to obtain a thin slice of a muscular body area? A) Computed tomography (CT) B) Magnetic resonance imaging (MRI) C) Positron emission tomography (PET) D) Single-photon emission computed tomography (SPECT)
Ans: A Feedback: A computer tomography scan uses x-rays and computer analysis to produce three-dimensional views of the slices of the body. This is a good first test to obtain information. An MRI uses radiofrequency waves to produce images of tissue. PET scans use radioactive substances to examine metabolic activity and organ involvement. SPECT is an imaging tool that examines cerebral blood flow.
4. A female client undergoes a scheduled electroencephalogram (EEG). Which of the following postprocedure activities should the nurse carry out for the client? A) Allow the client to rest and shampoo the client's hair. B) Provide the client with adequate caffeine-rich drinks. C) Measure the level of consciousness (LOC) of the client. D) Measure the heart and the pulse rate.
Ans: A Feedback: After an EEG, the nurse should ensure rest for the sleep-deprived client and shampoo the client's hair to remove the glue used to affix electrodes to the scalp. The client is advised not to take sedative drugs and caffeine-related drinks before the EEG, and there is no reason to provide the client with them after the test. The nurse should not measure the LOC, the heart rate, or the pulse rate of the client unless advised by the physician.
9. A client presents to the emergency department status postseizure. The physician wants to know what the pressure is in the client's head. What test might be ordered on this client? A) Lumbar puncture B) Echoencephalography C) Nerve conduction studies D) EMG
Ans: A Feedback: Changes in CSF occur in many neurologic disorders. A lumbar puncture (spinal tap) is performed to obtain samples of CSF from the subarachnoid space for laboratory examination and to measure CSF pressure. Echoencephalography records the electrical impulses generated by the brain. Nerve conduction studies measure the speed with which the nerve impulse travels along the peripheral nerve. Electromyography studies the changes in the electrical potential of muscles and the nerves supplying the muscles.
2. The critical care nurse is giving report on a client she is caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? A) Comatose B) Somnolence C) Stupor D) Normal
Ans: A Feedback: The GSC is used to measure the LOC. The scale consists of three parts: eye opening response, best verbal response, and best motor response. A normal response is 15. A score of 7 or less is considered comatose. Therefore, a score of 6 indicates the client is in a state of coma and not in any other state such as stupor or somnolence. The evaluations are recorded on a graphic sheet where connecting lines show an increase or decrease in the LOC.
21. 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. A) Unequal pupils B) Pupil reaction quick C) Pinpoint pupils D) Absence of pupillary response E) Pupil reacts to light
Ans: A, C, D Feedback: Normal assessment findings includes that the pupils are equal and reactive to light. Pupils that are unequal, pinpoint in nature, or fail to respond indicate a neurologic impairment.
31. The nurse is assessing a client's ability to detect sensation in the upper extremity. Which nursing actions would be appropriate? Select all that apply. A) Place a warm cotton ball on the arm. B) A light prick using a needle. C) A gentle pinch using the fingers. D) Drag the alcohol pad over the skin. E) Touch the client with the pads of the finger.
Ans: A, C, D, E Feedback: Sensory function can be assessed in a number of ways as long as the client has the ability to feel sensations. Common methods include placing a warm cotton balls on the skin, gently pinching on the skin between fingers, dragging alcohol over the skin, and touching the client with the pads of the fingers. The nurse would not use an instrument that would break the skin.
24. The nurse is caring for a post-lumbar puncture client experiencing an intense headache. The physician is notified and arriving to assess the client. If the physician chooses aggressive treatment, which nursing action is anticipated? A) Hanging an intravenous solution B) Drawing venous blood to perform a blood patch C) Applying ice to the back of the neck D) Offering caffeinated drinks
Ans: B Feedback: Aggressive treatment would include performing a blood patch by instilling 20 to 30 mL of the client's venous blood into the epidural space to seal the leak of CSF fluid. Increasing fluid intake and instilling parenteral caffeine sodium benzoate are less aggressive treatments. Applying ice to the head is a conservative treatment.
27. 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? A) Bronchodilator B) Antihistamine C) Cardiotonic D) Antibiotic
Ans: B Feedback: Clients with an allergy history are administered a pretest dose of an antihistamine. Antihistamines block histamine receptors and reduce the manifestations of an allergic reaction. The other options are not administered in the pretest period.
17. The nurse is caring for a client in the emergency department with diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the client's face and torso. For which action, made by the nurse aide, would the nurse provide further instruction? A) The nurse aide used mild soapy water to clean the face. B) The nurse aide moved the client's head to clean behind the ears. C) The nurse aide cleaned the eye area from the inner to outer eye area. D) The nurse aide cleaned the neck and upper chest area.
Ans: B Feedback: Further instruction would be provided to the nurse aide when the nurse aide attempted to move the client's head to clean behind the ears. There should be no movement of the client's head when there is a history of head trauma. Cleaning the client's face with soapy water, cleaning the eye area, and cleaning the neck and upper chest are all appropriate actions completed by the nurse aide.
18. The nurse is caring for a stuporous client in the intensive care unit. Which assessment finding is documented to reflect an improvement in the client's level of consciousness? A) Conscious B) Somnolent C) Stuporous D) Semicomatose
Ans: B Feedback: Somnolent or lethargic means that the client is drowsy or sleepy at inappropriate times. This is an improvement from the stuporous state, which includes arousing the client only with vigorous and repeated stimulation. A client that is conscious is alert and responds to stimulation immediately. A client is documented as semicomatose when the client only responds to superficial, relatively mild painful stimuli.
23. The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern? A) Physician maintains aseptic procedure. B) Cerebrospinal fluid is cloudy in nature. C) Client states a piercing feeling. D) Client states a pressure relief in the head.
Ans: B Feedback: The nurse would note a concern as being the cerebrospinal fluid as cloudy in nature. Cloudy fluid is an indication of infection. The physician is correct to maintain aseptic procedure. A piercing feeling and pressure relief is a common feeling during and after the procedure.
16. When completing a neurologic examination on a client, which question is most essential to evaluate the accuracy of the data? A) When, if any, was your last narcotic use? B) Do you have any history of forgetfulness? C) Have you been diagnosed with any mental health issues? D) Have you experienced any unusual sensations?
Ans: A Feedback: When completing a neurologic exam, it is essential to assess the use of morphine, heroin, narcotic, or central nervous system depressant use because the use affects the results of a neurologic examination. These types of drugs decrease the level of consciousness. The nurse can observe forgetfulness and mental status. Experiencing unusual sensations is good subjective data to have but is not essential to evaluate the accuracy of objective data.
6. 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? A) Administer antihistamines to the client. B) Provide adequate caffeine-rich drinks to the client. C) Assess the level of consciousness (LOC) and the pupil response of the client. D) Position the client flat for at least 3 hours.
Ans: D Feedback: A client who has undergone a lumbar puncture should be positioned flat for at least 3 hours and given adequate fluids, and this is a priority activity. These measures help restore the cerebrospinal fluid volume extracted from the client. The client is administered antihistamines to manage any allergic reactions that may occur from the test. The nurse should assess the LOC or the pupil response of the client after a lumbar puncture. Parenteral administration of caffeine sodium benzoate may offset cerebral vasodilation.
11. Following a motorcycle accident, a client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure? A) Blood pressure 100/60 mm Hg B) Lethargy C) Nausea D) Periorbital edema
Ans: B Feedback: Decreasing level of consciousness is one of the earliest signs of increased ICP. Without a baseline for the BP, it is difficult to determine whether this is a significant change for this client. Vomiting (usually without forewarning of nausea) when associated with a head injury suggests increasing ICP. Perioribital edema is more suggestive of fluid overload than ICP.
10. A critical care nurse is documenting her assessment of a client she is caring for. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. What does this mean? A) The client has an abnormal posture response to stimuli. B) The client is not responding to stimuli. C) The client is hyperresponsive on the left. D) The client is hyporesponsive on the left.
Ans: B Feedback: Flaccidity is when the client makes no motor response to stimuli. Flaccidity is a motor assessment.
32. A nurse is working in a neurologist's office. The physician orders a Romberg test. Which nursing action is correct? A) Have the client touch his nose with one finger. B) Have the client close his eyes and stand erect. C) Have the client close his eyes and discriminate between dull and sharp. D) Have the client close his eyes and jump on one foot.
Ans: B Feedback: In the Romberg test, the client stands erect with the feet close together and eyes closed. If the client sways and appears to fall, it is considered a positive Romberg test. All of the other options include components of neurologic tests, indicating neurologic deficits and balance.
12. The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse is correct to instruct on the action of which system? A) Musculoskeletal system B) Sympathetic nervous system C) Parasympathetic nervous system D) Endocrine system
Ans: B Feedback: The division of the autonomic nervous system called the sympathetic nervous system regulates the expenditure of energy. The neurotransmitters of the sympathetic nervous system are called catecholamines. During an emergency situation or an intensely stressful event, the body adjusts to deliver blood flow and oxygen to the brain, muscles, and lungs that need to react in the situation. The musculoskeletal system benefits from the sympathetic nervous system as the fight-or-flight effects pump blood to the muscles. The parasympathetic nervous system works to conserve body energy not expend it during an emergency. The endocrine system regulates metabolic processes.
29. The nurse is caring for a client in the neurologic intensive care unit. The nurse is noting from the assessment findings that the client is lacking a connection because motor impulses are interrupted from the brain to the spinal cord. It also appears that the client lacks sensory impulses from the peripheral sensory neurons to the brain. Which area has the deficit? A) Midbrain B) Medulla oblongata C) Pons D) Subarachnoid space
Ans: B Feedback: The medulla oblongata lies below the pons and transmits motor impulses from the brain to the spinal cord and sensory impulses from the peripheral sensory neurons to the brain. The pons is part of the brainstem. The midbrain forms the forward part of the brainstem and connects the pons and the cerebellum with the two cerebral hemispheres. The subarachnoid space lies between the pia mater and the arachnoid membrane.
3. The nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response? A) Observing the reaction of pupils to light B) Observing the client's response to painful stimulus C) Using the Romberg test D) Assessing the client's sensitivity to temperature, touch, and pain
Ans: B Feedback: The nurse evaluates motor response in a comatose or unconscious client by administering a painful stimulus. This action helps determine if the client makes an appropriate response by reaching toward or withdrawing from the stimulus. The Romberg test is used to assess equilibrium in a noncomatose client. Pupils are examined for their reaction to light to assess sensitivity in the third cranial (oculomotor) nerve. Sensitivity to temperature, touch, and pain is a test to assess the sensory function of the client and not motor response.
28. A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate? A) Abnormal posture B) Flaccidity C) Weak muscular tone D) Decorticate posturing
Ans: B Feedback: The nurse would document flaccidity when the client makes no motor response to stimuli. Abnormal posturing and weak motor tone would be documented specifically as the nurse would assess. Decorticate posturing is when a client is stiff with bent arms and clenched fists with legs straight out.
13. The nurse is caring for a client who is to have a lumbar puncture. What are the lowest vertebrae that contain the spinal cord? A) Coccyx B) Second lumbar vertebrae C) Eleventh thoracic vertebrae D) Fifth lumbar vertebrae
Ans: B Feedback: The spinal cord ends between the first and second lumbar vertebrae.
34. The client is waiting in a triage area to learn the medical status of his family following a motor vehicle accident. The client is pacing, taking deep breaths, and wringing the hands. Considering the effects in the body systems, what effects does the nurse anticipate in the liver? A) The liver will cease function and shunt blood to the heart and lungs. B) The liver will convert glycogen to glucose for immediate use. C) The liver will produce a toxic by product in relation to stress. D) The liver will maintain a basal rate of functioning.
Ans: B Feedback: When the body is under stress, the sympathetic nervous system is activated readying the body for action. The effect of the body is to mobilize stored glycogen to glucose to provide additional energy for body action.
20. The nurse is scoring the client's level of consciousness using the Glasgow Coma Scale. Which score would indicate to the nurse that the client is in a semicomatose state? A) A score of 20 B) A score of 15 C) A score of 9 D) A score of 4
Ans: C Feedback: A score of 9 indicates a semicomatose state. A score of 7 or less is considered a coma. A normal response is documented as a 15. A score of 20 indicates inappropriate scoring. A score of 4 carries an extremely poor prognosis.
34. A client with increased intracranial pressure is receiving mannitol (Osmitrol) via intravenous infusion. Which assessment finding is most important in determining the effectiveness of this treatment? A) Blood pressure is rising. B) Level of consciousness is improving. C) Urine output is increased. D) Hyperpyrexia is resolving.
Ans: C Feedback: Mannitol is a hypertonic solution that helps to pull fluid from the cells into the vascular system where the kidneys can eliminate as urine. The blood pressure should lower as the fluid volume is depleted. Level of consciousness may improve as the ICP is lowered, but the use of mannitol is for diuresis. Resolving fever is not significant with the use of mannitol.
5. The nurse is caring for a client who is undergoing single-photon emission computed tomography (SPECT). What is a potential side effect that this client may suffer? A) Headache and pain in the neck B) Claustrophobia C) Allergic reaction to the imaging material D) Allergic reaction to radioactive rays
Ans: C Feedback: SPECT obtains images of the brain after the client intravenously receives radiopharmaceuticals and radioisotopes approximately 1 hour before the test begins. A potential risk of SPECT is the client's allergic reaction to the imaging material. Headache is an aftereffect of a cisternal puncture, and claustrophobia may be experienced by clients during a magnetic resonance imaging scan.
19. The nurse is assessing the assigned client's level of consciousness during morning rounds. The nurse speaks the client's name, strokes the client's hand, and moves the client's shoulder. There is a delay, and then the client states, "What do you want?" Which level of conscious should the nurse document? A) Conscious B) Semicomatose C) Somnolent D) Stuporous
Ans: C Feedback: Somnolent or lethargy means that the client is drowsy or sleepy at inappropriate times. This is an improvement from the stuporous state, which includes arousing the client only with vigorous and repeated stimulation. A client that is conscious is alert and responds to stimulation immediately. A client is documented as semicomatose when the client only responds to superficial, relatively mild painful stimuli.
26. The nurse is working in an outpatient studies unit administering neurologic tests. The client is surprised that paste is used to secure an electroencephalogram and asks how it will be removed from the hair. The nurse is most correct to state which? A) The paste is removed with acetone. B) The paste is removed with a special soap. C) The paste is removed with standard shampoo. D) The paste is removed by flushing with warm water.
Ans: C Feedback: Standard shampoo is used to remove the paste, which attached the electrodes to the head. Acetone is not used on the hair. There is no special soap needed. More than warm water is needed to lift and remove the paste.
The family nurse practitioner is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly? A) Moving the head toward both sides B) Lightly tapping the lower portion of the neck to detect sensation C) Moving the head and chin toward the chest D) Gently pressing the bones on the neck
Ans: C Feedback: The neck is examined for stiffness or abnormal position. The presence of rigidity is assessed by moving the head and chin toward the chest. The nurse should not maneuver the neck if a head or neck injury is suspected or known. The neck should also not be maneuvered if trauma to any part of the body is evident. Moving the head toward the sides or pressing the bones on the neck will not help assess for neck rigidity correctly. While assessing for neck rigidity, sensation at the neck area is not to be assessed.
33. The nurse is caring for a client newly diagnosed with multiple sclerosis. The client indicates that there is so much to understand at one time. The client indicates understanding that there is a disruption in the covering of axons but does not remember what the covering is called. Which nursing action is correct? A) Tell the client not to worry about the fine details. B) Tell the client that there is so much to learn; you can meet to discuss it again. C) Tell the client that the covering is called myelin and that you can discuss at the next meeting. D) Tell the client that the disease process requires more research.
Ans: C Feedback: The nurse would be most correct in answering the question and then, if the patient is tired, following up at the next meeting. It would also be appropriate to provide literature to review at the client's leisure. Discounting the need to know information about the disease process is belittling. Telling the client that more research needs to be done discounts the valuable information which is known.
14. The nurse is employed in a neurologist's office, 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? A) Cranial nerve II B) Cranial nerve VI C) Cranial nerve VIII D) Cranial nerve XI
Ans: C Feedback: There are 12 pairs of cranial nerves. Cranial nerve VIII is the vestibulocochlear or auditory nerve responsible for hearing and balance. Cranial nerve II is the optic nerve. Cranial nerve VI is the abducens nerve responsible for eye movement. Cranial nerve XI is the accessory nerve and is involved with head and shoulder movement.
15. The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve? A) Cranial nerve I B) Cranial nerve V C) Cranial nerve XI D) Cranial nerve XII
Ans: D Feedback: Assessment of the movement of the tongue is cranial nerve XII. Cranial nerve I is the olfactory nerve. Cranial nerve V is the trigeminal nerve responsible for sensation to the face and chewing. Cranial nerve XI is the spinal or accessory nerve responsible for head and shoulder and shoulder movement.
11. 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 slowing transmission of the motor neurons, which deficits are anticipated? A) A delayed reaction in identification of information due to slowed passages of information to brain B) A delayed reaction in cognitive ability to understand the relayed information C) A delayed reaction in processing the information transferred from the environment D) A delayed reaction in response due to the interrupted impulses from the central nervous system
Ans: D Feedback: The central nervous system is composed of the brain and the spinal cord. Motor neurons transmit impulses from the central nervous system. A deficit in slowing transmission in this area would slow the response of transmission leading to a delay in reaction. Sensory neurons transmit impulses from the environment to the central nervous system, allowing identification of a stimulus. Cognitive centers of the brain interpret the information.
8. The brain stem holds the medulla oblongata. What is the function of the medulla oblongata? A) Transmits sensory impulses from the brain to the spinal cord B) Controls striated muscle activity in blood vessel walls C) Controls parasympathetic nerve impulses in the pons D) Transmits motor impulses from the brain to the spinal cord
Ans: D Feedback: The medulla oblongata lies below the pons and transmits motor impulses from the brain to the spinal cord and sensory impulses from peripheral sensory neurons to the brain. The medulla contains vital centers concerned with respiration, heartbeat, and vasomotor activity (the control of smooth muscle activity in blood vessel walls).
25. The physician's office 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? A) Myelogram B) Electroencephalogram C) Echoencephalography D) Cerebral angiography
Ans: D Feedback: The nurse would anticipate a cerebral angiography, which detects distortion of the cerebral arteries and veins. A myelogram detects abnormalities of the spinal canal. An electroencephalogram records electrical impulses of the brain. An echoencephalography is an ultrasound of the structures of the brain.
30. A nurse is completing a neurological assessment and determines that the client has significant visual deficits. A brain tumor is considered. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit? A) Frontal B) Parietal C) Temporal D) Occipital
Ans: D Feedback: The vision center is located in the occipital lobe. There is little other functioning that may interfere with the visual process in the other lobes of the brain.
13. A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? A) Dextrose 5% in water (D5W) B) Half-normal saline (0.45% NSS) C) One-third normal saline (0.33% NSS) D) Mannitol (Osmitrol)
Ans: D Feedback: With increasing ICP, hypertonic solutions, like mannitol, are used to decrease swelling in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that will move more fluid into the cells, worsening the ICP.
12. Which of the following assessment findings would indicate an increasing intracranial pressure (ICP) in a client with head trauma? Select all that apply. A) Stiff neck B) Generalized pain C) Glasgow Coma Scale of 15 D) Elevated systolic blood pressure E) Brisk pupil response F) Wide pulse pressure
Ans: D, F Feedback: Elevated systolic blood pressure with widening pulse pressure is consistent with Cushing's triad, which occurs late in increasing ICP. Other signs of Cushing's triad include bradycardia and irregular breathing. Stiff neck is not a symptom associated with ICP. Generalized pain is not significant with ICP unless related to complaint of headache (especially upon awakening). Glasgow Coma Scale of 15 and brisk pupil response are normal findings.
