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43 terms

Chapt 60,61,62

Nurse observes pt has extentin and external rotation of hte arms and wrist and extention, plantar flexion and internal rotation of the feet.
decerebrate :
whichi of hte following terms refer to the failure to recognize familiar objects as perceived by the sense?
auditory agnosia - sound
agraphia - writing intelligible words
apraia- ability to perform prev learned motor activities
perseveratoin is cont and auto repitittion of activity, word or phrase that is no longer appropriate
term refers to muscular hypertonicity adn increased resistance to stretch
health promotion efforts to decrease the risk for ischemis stroke involve encouraging a healthy lifestyle
low fat low cholesterol and increasing exercise
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.
The client with damage to the fronal cortex will display a deficit in intellectual functioning. Questions designed to assess this capacity might include the ability to recognize similarities: for example, how are a mouse and dog or pen and pencil alike?
A patient is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in which of the following?
Thought content
Hallucinations are a disturbance of thought content. They are not disturbances in motor ability, intellectual function, or emotional status.
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
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
The patient is exhibiting signs of expressive aphasia with numbness/tingling and weakness of the right arm and leg. This indicates injury to the expressive speech center (Broca's area), which is located in the inferior portion of the frontal lobe. The motor strip is located in the posterior portion of the frontal lobe. The sensory strip is located in the anterior parietal lobe.
A female client has undergone a lumbar puncture for a neurological assessment. The client is put under the post-procedure care of a nurse. Which of the following important post-procedure nursing interventions should be performed to ensure maximum comfort to the client? Choose all that apply.
• Encourage a liberal fluid intake for the client.
• Position the client flat for at least three hours or as directed by the physician.
In reviewing a client's history and physical examination, a nurse finds that the client was found positive for ataxia during the physician's neurological testing. Which nursing diagnosis will be a priority for this client?
Risk for falls
Which of the following terms refers to the inability to coordinate muscle movements, resulting difficulty walking?
Lower motor neuron lesions cause
Lower motor neuron lesions cause flaccid muscle paralysis, muscle atrophy, decreased muscle tone, and loss of voluntary control.
A client preparing to undergo a lumbar puncture states he doesn't think he will be able to get comfortable with his knees drawn up to his abdomen and his chin touching his chest. He asks if he can lie on his left side. Which statement is the best response by the nurse?
"Although the required position may not be comfortable, it will make the procedure safer and easier to perform."
Which of the following cerebral lobes contains the auditory receptive areas?
A female patient has undergone a lumbar puncture for a neurological assessment. The patient is put under the postprocedure care of a nurse. Which of the following important postprocedure nursing interventions should be performed to ensure maximum comfort to the patient?
Encourage a liberal fluid intake for the patient
A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following?
"The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid."
Which of the following terms refer to a method of recording, in graphic form, the electrical activity of the muscle?
Which cranial nerve is tested by listening to a ticking watch?
The Family Nurse Practitioner is assessing a 55-year-old who came to the clinic complaining of being "unsteady" on their feet. What would be a test for equilibrium?
Romberg test
Explanation: In the Romberg test, the client stands with feet close together and eyes closed.
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.
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.
Which of the following areas of the brain are responsible for temperature regulation?
Which lobe of the brain is responsible for concentration and abstract thought?
Which lobe of the brain is responsible for concentration and abstract thought?
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.
A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for:
Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing, and coughing. Therefore, the nurse should monitor the client closely for hypoxia. Temperature control, vision, and gait aren't lower brain stem functions.
Which of the following cranial nerves is responsible for muscles that move the eye and lid?
The spinal cord is composed of 31 pairs of spinal nerves. How many pairs of thoracic nerves are contained within the spinal column?
In a typical spinal cord, it functions as a "highway" for sensory and descending motor neurons - to provide conduction of impulses to and from the brain. The spinal cord is surrounded and protected by bony vertebrae. Where does the spinal cord end?
Between the first and second lumbar vertebrae
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 lobe of the brain is responsible for spatial relationships?
Which of the following neurotransmitters are deficient in myasthenia gravis?
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
The nurse is preparing a client for a neurological examination by the physician and explains tests the physician will be doing, including the Romberg test. The client asks the purpose of this particular test. The correct reply by the nurse is which of the following?
"It is a test for balance."
Which of the following terms refers to the inability to recognize objects through a particular sensory system?
A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with:
body temperature control.
What safety actions does the nurse need to take for a patient on oxygen therapy who is undergoing magnetic resonance imaging (MRI)?
Ensure that no patient care equipment containing metal enters the room where the MRI is located
Which of the following is an age-related change in the nervous system?
Loss of neurons in the brain
What is the function of cerebrospinal fluid (CSF)?
It cushions the brain and spinal cord.
Which neurotransmitter demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways?
Which of the following are sympathetic effects of the nervous system?
Dilated pupils
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?
Which of the following is a sympathetic nervous system effect?
Decreased peristalsis