Lewis Chapter 60

When admitting an acutely confused patient with a head injury, which action should the nurse take?

a. Ask family members about the patient's health history.

b. Ask leading questions to assist in obtaining health data.

c. Wait until the patient is better oriented to ask questions.

d. Obtain only the physiologic neurologic assessment data.

ANS: A

When admitting a patient who is likely to be a poor historian, the nurse should obtain health history information from others who have knowledge about the patient's health. Waiting until the patient is oriented or obtaining only physiologic data will result in incomplete assessment data, which could adversely affect decision making about treatment. Asking leading questions may result in inaccurate or incomplete information.

Which finding should the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion?

a. Spasticity

b. Flaccidity

c. Impaired sensation

d. Hyperactive reflexes

ANS: B

Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor neuron lesions.

What should the nurse include in a focused assessment of a patient's left posterior temporal lobe functions?

a. Sensation on the left side of the body

b. Reasoning and problem-solving ability

c. Ability to understand written and oral language

d. Voluntary movements on the right side of the body

ANS: C

The posterior temporal lobe integrates the visual and auditory input for language comprehension. Reasoning and problem solving are functions of the anterior frontal lobe. Sensation on the left side of the body is located in the right postcentral gyrus. Voluntary movement on the right side is controlled in the left precentral gyrus.

How should the nurse assess the patient's trigeminal and facial nerve function (CNs V and VII)?

a. Check for unilateral eyelid droop.

b. Shine a light into the patient's pupil.

c. Touch a cotton wisp strand to the cornea.

d. Have the patient read a magazine or book.

ANS: C

The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to evaluate function of the oculomotor nerve.

Which action should the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)?

a. Assist to stand and ambulate.

b. Withhold oral fluids and food.

c. Insert an oropharyngeal airway.

d. Apply artificial tears every hour.

ANS: B

The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. A patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve. Balance and coordination are cerebellar functions.

An unconscious male patient has just arrived in the emergency department with a head injury caused by a motorcycle crash. Which planned intervention by the health care provider should the nurse question?

a. Obtain x-rays of the skull and spine.

b. Prepare the patient for lumbar puncture.

c. Send for computed tomography (CT) scan.

d. Perform neurologic checks every 15 minutes.

ANS: B

After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure. Herniation of the brain could result if lumbar puncture is performed. The other orders are appropriate.

A patient with suspected meningitis is scheduled for a lumbar puncture. What action should the nurse take before the procedure?

a. Enforce NPO status for 4 hours.

b. Transfer the patient to radiology.

c. Administer a sedative medication.

d. Help the patient to a lateral position.

ANS: D

For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration.

During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurse's directions to move his hands and feet. What should the nurse suspect as a likely cause of these findings?

a. Cerebellar injury

b. A brainstem lesion

c. Frontal lobe damage

d. A temporal lobe lesion

ANS: C

Expressive speech (ability to express the self in language) is controlled by Broca's area in the frontal lobe. The temporal lobe contains Wernicke's area, which is responsible for receptive speech (ability to understand language input). The cerebellum and brainstem do not affect higher cognitive functions such as speech.

A patient has a tumor in the cerebellum. What goal should the nurse use to focus the plan of care?

a. Prevent falls.

b. Stabilize mood.

c. Avoid aspiration.

d. Improve memory.

ANS: A

Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability.

Which problem should the nurse expect for a patient who has a positive Romberg test result?

a. Pain

b. Falls

c. Aphasia

d. Confusion

ANS: B

A positive Romberg test result indicates that the patient has difficulty maintaining balance when standing with the eyes closed. The Romberg test does not assess orientation, thermoregulation, or discomfort.

Which test should the nurse anticipate discussing with a patient who has a possible seizure disorder?

a. Cerebral angiography

b. Evoked potential studies

c. Electromyography (EMG)

d. Electroencephalography (EEG)

ANS: D

Seizure disorders are usually assessed using EEG testing. Evoked potential is used to diagnose problems with the visual or auditory systems. Cerebral angiography is used to diagnose vascular problems. EMG is used to evaluate electrical innervation to skeletal muscle.

Which equipment should the nurse obtain to assess vibration sense in a patient with diabetes who has peripheral nerve dysfunction?

a. Sharp pin

b. Tuning fork

c. Reflex hammer

d. Calibrated compass

ANS: B

Vibration sense is testing by touching the patient with a vibrating tuning fork. The other equipment is needed for testing of pain sensation, reflexes, and two-point discrimination.

Which information about a 76-yr-old patient should the nurse identify as uncharacteristic of normal aging?

a. Triceps reflex response graded at 1/5

b. Unintended weight loss of 15 pounds

c. Patient report of chronic difficulty in falling asleep

d. 10 mm Hg orthostatic drop in systolic blood pressure

ANS: B

Although changes in appetite are normal with aging, a 15-pound weight loss requires further investigation. Orthostatic drops in blood pressure, changes in sleep patterns, and slowing of reflexes are normal changes in aging.

The charge nurse is observing a new nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action by the new nurse indicates the need for further teaching about neurologic assessment?

a. Tests for light touch before testing for pain.

b. Has the patient close the eyes during testing.

c. Asks the patient if the instrument feels sharp.

d. Uses an irregular pattern to test for intact touch.

ANS: C

When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate.

Which cerebrospinal fluid analysis result should the nurse recognize as abnormal and communicate to the health care provider?

a. Specific gravity of 1.007

b. Protein of 65 mg/dL (0.65 g/L)

c. Glucose of 45 mg/dL (1.7 mmol/L)

d. White blood cell (WBC) count of 4 cells/μL

ANS: B

The protein level is high. The specific gravity, WBCs, and glucose values are normal.

A 39-yr-old patient with a suspected herniated intervertebral disc is scheduled for a myelogram. Which information communicated by the nurse to the health care provider before the procedure would change the procedural plans?

a. The patient is anxious about the test results.

b. The patient reports a previous allergy to shellfish.

c. The patient has back pain when lying flat for more than 4 hours.

d. The patient drank apple juice 4 hours before the scheduled procedure.

ANS: B

A contrast medium containing iodine is injected into the subarachnoid space during a myelogram. The patient's allergy would contraindicate the use of this medium. The health care provider may need to provide orders to treat back pain after the procedure. Clear liquids are usually considered safe up to 4 hours before a diagnostic or surgical procedure. The patient's anxiety should be addressed, but procedural plans would not need to be changed.

Which of the following should the nurse consider the priority nursing assessment for a patient being admitted with a brainstem infarction?

a. Pupil reaction

b. Respiratory rate

c. Reflex reaction time

d. Level of consciousness

ANS: B

Vital centers that control respiration are located in the medulla and part of the brainstem. They require priority assessments because changes in respiratory function may be life threatening. The other information will also be obtained by the nurse but is not as urgent.

Several patients have been hospitalized for diagnosis of neurologic problems. Which patient should the nurse assess first?

a. A patient with a transient ischemic attack (TIA) returning from carotid duplex studies

b. A patient with a brain tumor who has just arrived on the unit after a cerebral angiogram

c. A patient with a seizure disorder who has just completed an electroencephalogram (EEG)

d. A patient prepared for a lumbar puncture whose health care provider is waiting for assistance

ANS: B

Because cerebral angiograms require insertion of a catheter into the femoral artery, bleeding is a possible complication. The nurse will need to check the pulse and blood pressure and assess the catheter insertion site in the groin as soon as the patient arrives. Carotid duplex studies and EEG are noninvasive. The nurse will need to assist with the lumbar puncture as soon as possible but monitoring for hemorrhage after cerebral angiogram has a higher priority.

Which assessments should the nurse make to monitor a patient’s cerebellar function?

Select all that apply

a. Test for graphesthesia.

b. Observe arm swing with gait.

c. Perform the finger-to-nose test.

d. Assess heat and cold sensation.

e. Measure strength against resistance.

ANS: B, C

The cerebellum is responsible for coordination and is assessed by looking at the patient's gait and the finger-to-nose test. The other assessments will be used for other parts of the neurologic assessment.

Which nursing actions should be included in the plan of care for a patient after cerebral angiography?

Select all that apply

a. Monitor for photophobia.

b. Observe for bleeding at the puncture site.

c. Keep patient NPO until gag reflex returns.

d. Check pulse and blood pressure frequently.

e. Assess orientation to person, place, and time.

ANS: B, D, E

Because a catheter is inserted into an artery (e.g., the femoral artery) during cerebral angiography, the nurse should assess for bleeding at the site and bleeding that may affect pulse and blood pressure. Neuro status should be assessed often. There is no reason to keep the patient NPO. Photophobia is not expected.

A patient with heart failure and type 1 diabetes is scheduled for a positron emission tomogram (PET) of the brain. Which medication would the nurse expect to administer before the study?

a. Furosemide 20 mg IV

b. Alprazolam 0.5 mg oral

c. Ciprofloxacin 500 mg oral

d. Regular insulin 6 units subcutaneous

ANS: D

Patients with type 1 diabetes must receive insulin the day of the PET if glucose metabolism is the focus of the PET. Diuretics should not be administered before the PET unless a urinary catheter is inserted. The patient must remain still during the procedure (1 to 2 hours). Sedatives and tranquilizers (e.g., alprazolam) should not be administered before a PET of the brain because the patient may need to perform mental activities, and these medications may affect glucose metabolism. Prophylactic antibiotics are not necessary. Patients are NPO before a PET of the brain and should not receive oral medications (alprazolam and ciprofloxacin).

The nurse is caring for an older adult patient. Which normal nervous system changes of aging put this patient at higher risk of falls?

Select all that apply

a. Memory deficit

b. Sensory deficit

c. Motor function deficit

d. Cranial and spinal nerves

e. Reticular activation system

f. Central nervous system changes

ANS: B, C, F

Normal changes of aging in the nervous system decrease the sensory function that leads to poor ability to maintain balance and a widened gait. The motor function deficit decreases muscle strength and agility. The central nervous system changes in the brain lead to a diminished kinesthetic sense or position sense. These changes all contribute to an increased risk of falls for the older adult. Memory deficits, normal changes of cranial and spinal nerves, and the reticular activation system do not increase the risk for falls.

When assessing motor function of a patient admitted with a stroke, the nurse notes mild weakness of the arm. The patient also is unable to hold the arm level. How would the nurse document this finding?

a. Athetosis

b. Hypotonia

c. Hemiparesis

d. Pronator drift

ANS: D

Downward drifting of the arm or pronation of the palm is identified as pronator drift. Athetosis is a slow, writhing, involuntary movement of the extremities. Hypotonia is flaccid muscle tone, and hemiparesis is weakness of one side of the body.

How would the nurse most accurately assess the position sense of a patient with a recent traumatic brain injury?

a. Ask the patient to close their eyes and slowly bring the tips of the index fingers together.

b. Ask the patient to close their eyes and identify the presence of a common object on the forearm.

c. Ask the patient to stand with the feet together and eyes closed and observe for balance maintenance.

d. Place the two points of a calibrated compass on the tips of the fingers and toes and ask the patient to discriminate the points.

ANS: C

The Romberg test is an assessment of position sense in which the patient stands with the feet together and then closes their eyes while attempting to maintain balance. The other cited tests of neurologic function do not directly assess position sense.

A patient's sudden onset of hemiplegia has necessitated a CT scan of the head. Which action would be the nurse's priority before the study?

a. Assess the patient's immunization history.

b. Screen the patient for any metal parts or a pacemaker.

c. Assess the patient for allergies to shellfish, iodine, or dyes.

d. Assess the patient's need for tranquilizers or antiseizure medications.

ANS: C

Allergies to shellfish, iodine, or dyes contraindicate the use of contrast media in CT. The patient's immunization history is not a central consideration, and the presence of metal in the body does not preclude the use of CT as a diagnostic tool. The need to assess for allergies supersedes the need for tranquilizers or antiseizure medications in most patients.

In which patient would it be the most important for the nurse to assess the glossopharyngeal and vagus nerves?

a. A 50-yr-old woman with lethargy from a drug overdose

b. A 40-yr-old man with a complete lumbar spinal cord injury

c. A 60-yr-old man with severe pain from trigeminal neuralgia

d. A 30-yr-old woman with a high fever and bacterial meningitis

ANS: A

The glossopharyngeal and vagus nerves innervate the pharynx and are tested by the gag reflex. It is important to assess the gag reflex in patients who have a decreased level of consciousness, brainstem lesion, or disease involving the throat musculature. If the reflex is weak or absent, the patient is in danger of aspirating food or secretions.

When assessing a patient with a traumatic brain injury, the nurse notes uncoordinated movement of the extremities. How would the nurse document this finding?

a. Ataxia

b. Apraxia

c. Anisocoria

d. Anosognosia

ANS: A

Ataxia is a lack of coordination of movement, possibly caused by lesions of sensory or motor pathways, cerebellum disorders, or certain medications. Apraxia is the inability to perform learned movements despite having the desire and physical ability to perform them related to a cerebral cortex lesion. Anisocoria is inequality of pupil size from an optic nerve injury. Anosognosia is the inability to recognize a bodily defect or disease related to lesions in the right parietal cortex.

The nurse is preparing the patient for an electromyogram (EMG). What would the nurse include in teaching the patient before the test?

a. The patient will be tilted on a table during the test.

b. It is noninvasive, and there is no risk of electric shock.

c. The pain that occurs is from the insertion of the needles.

d. The passive sensor does not make contact with the patient.

ANS: C

With an EMG, pain may occur when needles are inserted to record the electrical activity of nerve and skeletal muscle. The patient is not tilted on a table during a myelogram. The electroencephalogram is noninvasive without a danger of electric shock. The magnetoencephalogram is done with a passive sensor that does not make contact with the patient.

The nurse is caring for a group of healthy older adults at a community day center. Which neurologic finding associated with aging would the nurse expect to note?

a. Quicker reaction time

b. Improved sense of taste

c. Orthostatic hypotension

d. Hyperactive deep tendon reflexes

ANS: C

Older adults are more likely to have orthostatic hypotension related to altered coordination of neuromuscular activity. Other neurologic changes in older adults include atrophy of taste buds with decreased sense of taste, below-average reflex score, diminished deep tendon reflexes, and slowed reaction times.

The nurse is completing an assessment for a newly admitted patient. How would the nurse assess cognitive function?

a. Ask the patient a question such as, "Who were the last 3 presidents?"

b. Evaluate level of consciousness, body posture, and facial expressions.

c. Observe for signs of agitation, anger, or depression during the health check.

d. Request that the patient mimic rapid alternating movements with both hands.

ANS: A

Cognition is one component of the mental status examination to determine cerebral functioning. Cognition is assessed by determining orientation, memory, general knowledge, insight, judgment, problem solving, and calculation. A question often used to determine cognition for adults living in the United States is, "Who were the last three presidents?" General appearance and behavior are additional components and include level of consciousness, body posture, and facial expressions. Mood and affect are assessed by observing for agitation, anger, or depression. Cerebellar function is determined by assessing balance and coordination. It may include testing rapid alternating movements of the upper and lower extremities.

The nurse is performing a neurologic assessment. When assessing the accessory nerve, what action would the nurse take?

a. Assess the gag reflex by stroking the posterior pharynx.

b. Ask the patient to shrug the shoulders against resistance.

c. Have the patient say "ah" while noting elevation of soft palate.

d. Ask the patient to push the tongue to either side against resistance.

ANS: B

The spinal accessory nerve is tested by asking the patient to shrug the shoulders against resistance and to turn the head to either side against resistance while observing the sternocleidomastoid muscles and the trapezius muscles. Assessing the gag reflex and saying "ah" are used to assess the glossopharyngeal and vagus nerves. Asking the patient to push the tongue to either side against resistance is used to assess the hypoglossal nerve.

The nurse is caring for a patient after a lumbar puncture. Which would be the nurse's priority action?

a. Assess for drainage or bleeding from the puncture site.

b. Monitor for bladder problems and bowel incontinence.

c. Maintain bed rest until lower extremities move normally.

d. Check for loss of muscle strength in the upper extremities.

ANS: A

After a lumbar puncture, the nurse would monitor the puncture site for drainage or bleeding. Other assessments include headache intensity, meningeal irritation (nuchal rigidity), signs and symptoms of local trauma (e.g., hematoma, pain), neurologic signs, and vital signs. A lumbar puncture does not affect bowel or bladder function or upper extremity muscle strength. Bed rest until lower extremity movement returns is indicated for the patient after spinal anesthesia.

The nurse is admitting a patient with frontal lobe dementia. What functional problems would the nurse expect?

a. Lack of reflexes

b. Endocrine problems

c. Higher cognitive function problems

d. Respiratory, vasomotor, and cardiac dysfunction

ANS: C

Because the frontal lobe is responsible for higher cognitive function, this patient may have difficulty with memory retention, voluntary eye movements, voluntary motor movement, and expressive speech. The lack of reflexes would occur if the patient had problems with the reflex arcs in the spinal cord. Endocrine problems would be evident if the hypothalamus or pituitary gland were affected. Respiratory, vasomotor, and cardiac dysfunction would occur if there were a problem in the medulla.

The nurse is caring for a patient with a neurologic disease that affects the pyramidal tract. What clinical manifestation would the nurse assess in this patient?

a. Impaired muscle movement

b. Decreased deep tendon reflexes

c. Decreased level of consciousness

d. Impaired sensation of touch, pain, and temperature

ANS: A

Among the most important descending tracts are the corticobulbar and corticospinal tracts, collectively termed the pyramidal tract. These tracts carry volitional (voluntary) impulses from the cortex to the cranial and peripheral nerves. Dysfunction of the pyramidal tract is likely to manifest as impaired movement because of hypertonicity. Diseases affecting the pyramidal tract do not result in changes in level of consciousness, impaired reflexes, or decreased sensation.

A patient is having a transsphenoidal hypophysectomy. The nurse would provide preoperative patient teaching about what potential deficit after surgery?

a. Increased heart rate

b. Loss of coordination

c. Impaired swallowing

d. Altered sense of smell

ANS: D

Using a transsphenoidal approach to remove the pituitary gland includes a risk of damage to the olfactory cranial nerve because the cell bodies of the olfactory nerve are located in the nasal epithelium. With damage to this nerve, the sense of smell would be altered. Increased heart rate, loss of coordination, and impaired swallowing will not be potential deficits from this surgery.