Chapter 56: Nursing Assessment: Nervous System
Terms in this set (20)
When admitting an acutely confused 20-year-old 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.
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 treatmenvt. Asking leading questions may result in inaccurate or incomplete information.
2. Which finding would the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion?
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.
The nurse performing a focused assessment of left posterior temporal lobe functions will assess the patient for
a.sensation on the left side of the body.
b.voluntary movements on the right side.
c.reasoning and problem-solving abilities.
d.understanding written and oral language.
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.
Propranolol (Inderal), a b-adrenergic blocker that inhibits sympathetic nervous system activity, is prescribed for a patient who has extreme anxiety about public speaking. The nurse monitors the patient for
Inhibition of the fight or flight response leads to a decreased heart rate. Dry mouth, constipation, and urinary retention are associated with peripheral nervous system blockade.
To assess the functioning of the trigeminal and facial nerves (CNs V and VII), the nurse should
a.shine a light into the patient's pupil.
b.check for unilateral eyelid drooping.
c.touch a cotton wisp strand to the cornea.
d.have the patient read a magazine or book.
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 check function of the oculomotor nerve.
Which action will the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X)?
a.Withhold oral fluid or foods.
b.Provide highly seasoned foods.
c.Insert an oropharyngeal airway.
d.Apply artificial tears every hour.
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.
An unconscious male patient has just arrived in the emergency department after a head injury caused by a motorcycle crash. Which order 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.
7. ANS: B
After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure, which could lead to herniation of the brain if a lumbar puncture is performed. The other orders are appropriate.
A patient with suspected meningitis is scheduled for a lumbar puncture. Before the procedure, the nurse will plan to
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.
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. The nurse will suspect
b.a brainstem lesion.
c.frontal lobe damage.
d.a temporal lobe lesion.
Expressive speech is controlled by Broca's area in the frontal lobe. The temporal lobe contains Wernicke's area, which is responsible for receptive speech. The cerebellum and brainstem do not affect higher cognitive functions such as speech.
A 45-year-old patient has a dysfunction of the cerebellum. The nurse will plan interventions to
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 nursing diagnosis is expected to be appropriate for a patient who has a positive Romberg test?
b.Risk for falls
A positive Romberg test indicates that the patient has difficulty maintaining balance with the eyes closed. The Romberg does not test for orientation, thermoregulation, or discomfort.
The nurse will anticipate teaching a patient with a possible seizure disorder about which test?
b.Evoked potential studies
Seizure disorders are usually assessed using EEG testing. Evoked potential is used for diagnosing 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 nursing action will be included in the care for a patient who has had cerebral angiography?
a.Monitor for headache and photophobia.
b.Keep patient NPO until gag reflex returns.
c.Check pulse and blood pressure frequently.
d.Assess orientation to person, place, and time.
Because a catheter is inserted into an artery (such as the femoral artery) during cerebral angiography, the nurse should assess for bleeding after this procedure. The other nursing assessments are not necessary after angiography.
Which equipment will the nurse obtain to assess vibration sense in a diabetic patient who has peripheral nerve dysfunction?
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-year-old patient is most important for the admitting nurse to report to the patient's health care provider?
a.Triceps reflex response graded at 1/5
b.Unintended weight loss of 20 pounds
c.10 mm Hg orthostatic drop in systolic blood pressure
d.Patient complaint of chronic difficulty in falling asleep
Although changes in appetite are normal with aging, a 20-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 staff nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action indicates a need for further teaching of the new nurse about neurologic assessment?
a.The new nurse tests for light touch before testing for pain.
b.The new nurse has the patient close the eyes during testing.
c.The new nurse asks the patient if the instrument feels sharp.
d.The new nurse uses an irregular pattern to test for intact touch.
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 will be most important for the nurse to communicate to the health care provider?
a.Specific gravity 1.007
b.Protein 65 mg/dL (0.65 g/L)
c.Glucose 45 mg/dL (1.7 mmol/L)
d.White blood cell (WBC) count 4 cells/mL
The protein level is high. The specific gravity, WBCs, and glucose values are normal.
A 39-year-old patient with a suspected herniated intervertebral disc is scheduled for a myelogram. Which information is most important for the nurse to communicate to the health care provider before the procedure?
a.The patient is anxious about the test.
b.The patient has an allergy to shellfish.
c.The patient has back pain when lying flat.
d.The patient drank apple juice 4 hours earlier.
Iodine-containing contrast medium is injected into the subarachnoid space during a myelogram. The health care provider may need to modify the postmyelogram orders to prevent back pain, but this can be done 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 this is not as important as the iodine allergy.
The priority nursing assessment for a 72-year-old patient being admitted with a brainstem infarction is
a. reflex reaction time.
b.pupil reaction to light.
c.level of consciousness.
d.respiratory rate and rhythm.
Vital centers that control respiration are located in the medulla, and these are the priority assessments because changes in respiratory function may be life threatening. The other information will also be collected by the nurse, but it is not as urgent.
Several patients have been hospitalized for diagnosis of neurologic problems. Which patient will the nurse assess first?
a.Patient with a transient ischemic attack (TIA) returning from carotid duplex studies
b.Patient with a brain tumor who has just arrived on the unit after a cerebral angiogram
c.Patient with a seizure disorder who has just completed an electroencephalogram (EEG)
d.Patient prepared for a lumbar puncture whose health care provider is waiting for assistance
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, blood pressure, and 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.
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