Subtopic neurologic and sensory systems

When a disaster occurs, the nurse may have to first treat mass hysteria that is indicated by what response? 1 Panic 2 Coma 3 Euphoria 4 Depression

1 Panic People in a panic may initiate a group panic reaction even in those who appear to be in control. Comatose individuals will not cause panic in others. Euphoric individuals will not adversely affect others. Depressed people will be quiet and not affect others.

A client is admitted with a closed head injury sustained in a motor vehicle accident (MVA). The nursing assessment indicates increased intracranial pressure (ICP). Which intervention should the nurse perform first? 1 Place the head and neck in alignment. 2 Administer 1 gram mannitol intravenously (IV) as prescribed. 3 Increase the ventilator's respiratory rate to 20 breaths/minute. 4 Administer 100 mg of pentobarbital IV as prescribed.

1 Place the head and neck in alignment. The nurse should first attempt nursing interventions such as placing the head and neck in alignment (neutral position) to facilitate venous return and thereby decrease ICP. If nursing measures prove ineffective, notify the healthcare provider, who may prescribe mannitol. The nurse would notify the healthcare provider for hyperventilation therapy or for pentobarbital. Hyperventilation is used only when all other interventions have been ineffective in decreasing ICP.

During an annual physical assessment a client reports not being able to smell coffee and most foods. Which cranial nerve function should the nurse assess? 1) I 2) II 3) X 4) VII

1) I Cranial nerve I is the olfactory nerve that concerns the sense of smell [1] [2] [3]; the ability to sense odors usually is affected when an intracranial lesion is present. Cranial nerve II is the optic nerve and is concerned with sight. Cranial nerve X is the vagus nerve and is concerned with the gag reflex, supplying parasympathetic fibers to body organs, and transmitting sensory impulses from the viscera. Cranial nerve VII is the facial nerve and is concerned with facial expressions, taste, and the salivary glands.

A nurse is performing range-of-motion exercises with a client who had a cerebrovascular accident (CVA). The nurse places the client's hand in the position exhibited in the picture. What is the term for this position? 1 Flexion 2 Extension 3 Adduction 4 Circumduction

2 Extension The fingers are flared out in the extended, abducted position. The fingers are neither bent nor flexed. The fingers are abducted, not adducted, from the midline of the hand. Circumduction is a circular movement of a limb that occurs at a ball-and-socket joint. The shoulder and hip joints, not the wrist or fingers, can be moved in this way.

During the neurologic assessment of a client with a tentative diagnosis of Guillain-Barré syndrome, what does the nurse expect the client to manifest? 1 Diminished visual acuity 2 Increased muscular weakness 3 Pronounced muscular atrophy 4 Impairment in cognitive reasoning

2 Increased muscular weakness Muscular weakness with paralysis results from impaired nerve conduction because the motor nerves become demyelinated. Diminished visual acuity usually is not a problem; motor loss is greater than sensory loss, with paresthesia of the extremities being the most frequent sensory loss. Demyelination occurs rapidly early in the disease, and the muscles will not have had time to atrophy; this can occur later if rehabilitation is delayed. Only the peripheral nerves are involved; the central nervous system is unaffected.

A client with myasthenia gravis experiences generalized weakness. What is most important when planning this client's nursing care? 1 Maintaining bed rest 2 Providing frequent rest periods 3 Reassuring the client that there are many tasks that still can be performed 4 Arranging for a relative to be present

2 Providing frequent rest periods Spacing activities encourages maximum functioning within the limits of the client's strength and fatigue. Bed rest and limited activity may lead to muscle atrophy and calcium depletion and should be avoided. Although pointing out things the client can do is important, this does not address the client's concerns. Arranging for a relative to be present is unnecessary if the client is observed closely by the nursing staff; however, it should be permitted if requested by the client or family.

A nurse identifies that a client exhibits the characteristic gait associated with Parkinson disease. When recording on the client's record, what term does the nurse use to document this gait? 1 Ataxic 2 Shuffling 3 Scissoring 4 Asymmetric

2 Shuffling With a shuffling gait the steps are short and dragging; this is seen with basal ganglia defects. Ataxia is a staggering gait often associated with cerebellar damage. Scissoring is associated with bilateral spastic paresis of the legs. An asymmetric gait is associated with weakness of or pain in one lower extremity.

A nurse is assessing a client's eye and finds the following (see image). Which condition can be identified from the given figure? 1 Strabismus 2 Keratoconus 3 Corneal ulcer 4 Retinal detachment

3 Corneal ulcer The condition depicted in the figure is a corneal ulcer. Tissue loss due to an infection of the cornea causes corneal ulcers; the infection can be due to bacteria, a virus, or fungi. Strabismus is a condition of double vision; it can be due to neuromuscular problems of the eye. Keratoconus is a noninflammatory disease, where the anterior cornea thins and protrudes forward, taking on a cone shape. Retinal detachment is separation of the sensory retina and the underlying pigment epithelium with fluid accumulation between the two layers.

Which condition results in visual distortion? 1 Myopia 2 Hyperopia 3 Presbyopia 4 Astigmatism

4 Astigmatism Astigmatism is caused by unevenness in the cornea; this condition results in visual distortion. Myopia (nearsightedness) results in the blurred vision of distant objects. Hyperopia (farsightedness) results in the clear vision of distant objects and the blurred vision of close objects. Presbyopia is a condition related to older adults; this condition results in an inability to focus on near objects.

What is the nurse assessing when checking the cardinal positions from the image? 1 Color disability 2 Peripheral vision 3 Intraocular pressure 4 Extraocular muscle function

4 Extraocular muscle function Extraocular muscle function is assessed using the corneal light reflex and the six cardinal positions of cranial nerves III, IV, and VI. The Ishihara chart is used to determine colorblindness. Peripheral vision is determined by performing a test called perimetry; the confrontation test can be also be used for peripheral vision. Intraocular pressure is determined by performing tonometry.

A client is having a tonic-clonic seizure. Which is a priority nursing action? 1 Elevating the head of the bed 2 Restraining the client's arms and legs 3 Placing a tongue blade in the client's mouth 4 Taking measures to prevent injury

4 Taking measures to prevent injury Protecting the client from injury is the immediate priority during a seizure [1] [2]. Elevating the head of the bed would have no effect on the client's condition or safety. Restraining the client's arms and legs could cause injury. Placing a tongue blade or other object in the client's mouth could damage the teeth.

A client with a head injury is admitted to the hospital. Which assessment finding alerts the nurse to increasing intracranial pressure? 1 Hypervigilance 2 Constricted pupils 3 Increased heart rate 4 Widening pulse pressure

4 Widening pulse pressure Pressure on the vital centers in the brain causes an increase in the systolic blood pressure, widening the difference between the systolic and diastolic pressures. The client will be lethargic and have a lowered level of consciousness. The pupils will be unequal or dilated, not constricted. Pressure on the vital centers in the brain results in a decreased, not increased, heart rate.