PrepU Chapter 65
Which is a sympathetic effect of the nervous system?
Dilated pupils
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, the nurse would anticipate a delayed reaction in:
response due to interrupted impulses from the central nervous system
To evaluate a client's cerebellar function, a nurse should ask:
"Do you have any problems with balance?"
A patient arrives to have an MRI done in the outpatient department. What information provided by the patient warrants further assessment to prevent complications related to the MRI?
"I am trying to quit smoking and have a patch on."
A potential complication of a hemorrhagic stroke is interference with the ability of the arachnoid villi to absorb CSF. Therefore, fluid in the ventricles increase beyond the amount that is usually absorbed daily, which is:
"I am trying to quit smoking and have a patch on."
A nurse is preparing a client for lumbar puncture. The client has heard about post-lumbar puncture headaches and asks how to avoid having one. The nurse tells the client that these headches can be avoided by doing which of the following after the procedure?
"Remain prone for 2 to 3 hours."
The nurse is caring for a patient who was involved in a motor vehicle accident and sustained a head injury. When assessing deep tendon reflexes (DTR), the nurse observes diminished or hypoactive reflexes. How will the nurse document this finding?
1+
Which term refers to the inability to recognize objects through a particular sensory system?
Agnosia
A client undergoes a scheduled electroencephalogram (EEG). Which of the following post-procedure activities should the nurse carry out for the client?
Allow the client to rest and shampoo the client's hair.
A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first?
Assess the client for medication allergies.
Which term refers to the inability to coordinate muscle movements, resulting in difficulty walking?
Ataxia
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 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 II
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 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 nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?
Lateral recumbent, with chin resting on flexed knees
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?
Observing the client's response to painful stimulus
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 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?
Occipital
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?
Parasympathetic
A patient has difficulty interpreting his awareness of body position in space. Which lobe is most likely to be damaged?
Parietal
A client who has sustained a head injury to the parietal lobe cannot identify a familiar object by touch. The nurse knows that this deficit is which of the following?
Tactile agnosia
Which cerebral lobe contains the auditory receptive areas?
Temporal
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
A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with:
body temperature control.
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, the nurse anticipates that the liver will:
convert glycogen to glucose for immediate use.
During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates:
cranial nerves IX and X.
If a client has a lower motor neuron lesion, the nurse would expect the client to exhibiT?
decreased muscle tone.
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.
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:
sympathetic nervous system.
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.
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?
Cerebral angiography
A nurse is preparing a client for a lumbar puncture. The client has heard about post-lumbar puncture headaches and asks what causes them. The nurse tells the client that these headches are caused by which of the following?
Cerebral spinal fluid leakage at the puncture site
After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. 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.
Lower motor neuron lesions cause
flaccid muscles.
A client is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in
thought content.
Which of the following neurotransmitters are deficient in myasthenia gravis?
Acetylcholine
A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test?
Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
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
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
Cranial nerve IX is also known as which of the following?
Glossopharyngeal
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 frontoparietal region
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.
The spinal cord is composed of 31 pairs of spinal nerves. How many pairs of thoracic nerves are contained within the spinal column?
Twelve
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?
V
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 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
A client is scheduled for standard EEG testing to evaluate a possible seizure disorder. Which nursing intervention should the nurse perform before the procedure?
Withhold anticonvulsant medications for 24 to 48 hours before the exam
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
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. The nurse would provide further instruction after seeing that the nurse aide:
moved the client's head to clean behind the ears.
A client is scheduled for an EEG. The client asks about any diet-related prerequisites before the EEG. Which diet-related advice should the nurse provide to the client?
Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours before the test.
What safety actions does the nurse need to take for a client receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)?
Ensure that no client care equipment containing metal enters the room where the MRI is located.
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?
Flaccidity
Which cerebral lobes is the largest and controls abstract thought?
Frontal
Which lobe of the brain is responsible for concentration and abstract thought?
Frontal
The nurse is completing a neurological assessment and uses the whisper test to assess which cranial nerve?
Acoustic
Which cranial nerve is tested by listening to a ticking watch?
Acoustic
The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern?
Cerebrospinal fluid is cloudy in nature.
A nurse is completing a neurological assessment and determines that the client has significant visual deficits. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit?
occipital
Which of the following areas of the brain are responsible for temperature regulation?
Hypothalamus
The brain stem holds the medulla oblongata. What is the function of the medulla oblongata?
transmits motor impulses from the brain to the spinal cord
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.
A patient is treated for a neurologic dysfunction affecting facial expressions. The affected cranial nerve originates in the:
pons.
Which neurotransmitter demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways?
Serotonin
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.
The nurse is performing a neurological assessment of a client who has sustained damage to the frontal cortex. Which of the following deficits will the nurse look for during assessment?
The inability to tell how a mouse and a cat are alike
