Med Surg- Lewis chapter 56- nursing assessment Nervous sytem – Flashcards
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The nurse is caring for a group of well older people at a community day center. Which neurologic finding associated with aging would the nurse expect to find in older adults? A. Longer reaction time B. Improved sense of taste C. Orthostatic hypotension D. Hyperactive deep tendon reflexes
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Answer: C Older adults are more likely to experience orthostatic hypotension related to altered coordination of neuromuscular activity. Other neurologic changes in the older adult include atrophy of taste buds with decreased sense of taste, below average reflex score (and diminished deep tendon reflexes), and slowed reaction times.
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The nurse is completing a health assessment for an obese 62-year-old man who wants to begin a diet and exercise program. Which assessment should the nurse perform to determine the cognitive function of the patient during the physical examination? A. Ask the patient a question such as, "Who were the last three presidents?" B. Determine the 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.
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Answer: 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 is another component and includes 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 and may include testing rapid alternating movements of the upper and lower extremities.
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In which patient would it be the most important for the nurse to assess the glossopharyngeal and vagus nerves? A. A 50-year-old woman with lethargy from a drug overdose B. A 40-year-old man with a complete lumbar spinal cord injury C. A 60-year-old man with severe pain from trigeminal neuralgia D. A 30-year-old woman with a high fever and bacterial meningitis
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Answer: 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, a brainstem lesion, or a disease involving the throat musculature. If the reflex is weak or absent, the patient is in danger of aspirating food or secretions.
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The nurse cares for a 34-year-old woman after a lumbar puncture. Which action by the nurse is most appropriate? A. Assess for drainage or bleeding from the puncture site. B. Monitor for bladder dysfunction and bowel incontinence. C. Maintain bed rest until lower extremities move normally. D. Check for loss of muscle strength in the upper extremities.
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Answer: A After a lumbar puncture the nurse should 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. Awarded 1.0 points out of 1.0 possible points.
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A patient with heart failure and type 1 diabetes mellitus is scheduled for a positron emission tomography (PET) of the brain. Which medication prescribed by the health care provider should the nurse expect to administer before the diagnostic study? A. Regular insulin 6 units (SQ) B. Furosemide (Lasix) 20 mg (IV) C. Alprazolam (Xanax) 0.5 mg (PO) D. Ciprofloxacin (Cipro) 500 mg (PO)
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Answer: A Patients with type 1 diabetes mellitus must have insulin administered the day of the PET study if glucose metabolism is the focus of the PET. Diuretics should not be administered before the PET scan 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 study 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 study of the brain and should not receive oral medications (alprazolam and ciprofloxacin)
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In a patient with a disease that affects the myelin sheath of nerves, such as multiple sclerosis the glial cells affected are the? A. microglia b. Astrocytes. C. ependymal cells D. Oligodendrocytes
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Correct answer: D Rationale: Glial cell types include oligodendrocytes, astrocytes, ependymal cells, and microglia, and each has specific functions. Oligodendrocytes are specialized cells that produce the myelin sheath of nerve fibers in the central nervous system (CNS), and they are located primarily in the white matter of the CNS.
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Drugs or disease that impair the function of the extrapyramidal system may cause loss of? A. sensations of pain and temperature B. regulation of the automonic nervous system C. integration of somatic and special sensory inputs D. Automatic movements asociated with skeletal muscle activity
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Correct answer: D Rationale: A group of descending motor tracts carries impulses from the extrapyramidal system, which includes all motor systems (except the pyramidal system) concerned with voluntary movement. It includes descending pathways originating in the brainstem, basal ganglia, and cerebellum. The motor output exits the spinal cord by way of the ventral roots of the spinal nerves.
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An obstruction of the anterior cerebral arteries will affect functions of? A. Visual imaging B. balane and coordination C. Judgment, insight, and reasoning D. Visual and auditory integration for language comprehension
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Correct answer: c Rationale: The anterior cerebral artery feeds the medial and anterior portions of the frontal lobes. The anterior portion of the frontal lobe controls higher order processes such as judgment and reasoning.
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Paralysis of lateral gaze indicates a lesion of cranial nerve A. II B. III C. IV D. VI
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Correct answer: d Rationale: Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) are responsible for eye movement. The lateral rectus eye muscle is innervated by cranial nerve VI, and it is the primary muscle that is responsible for lateral eye movement.
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A result of stimulation of the parasympathetic nervous system is (select all that apply) A. constriction of the bronchi B. Dilation of skin blood vessels C. increased secreation of insulin D. increased blood glucose levels E. relaxation of the urinary sphincters
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Correct answers: a, b, c, e Rationale: Stimulation of the parasympathetic nervous system results in constriction of the bronchi, dilation of blood vessels to the skin, increased secretion of insulin, and relaxation of the urinary sphincter. Stimulation of the sympathetic nervous system results in increased blood glucose levels.
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Assessment of muscle strength of older adults cannot be compared with that of younger adults because? A. Stroke is more common in older adults B. Nutritional status is better in younger adults C. Most young people exercise more than older people D. Aging leads to a decrease in muscle bulk and strength
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Correct answer: d Rationale: Changes associated with aging include decreases in muscle strength and agility in relation to decreased muscle bulk.
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Data regarding mobility, strength, coordination and activity tolerance are important for the nurse to obtain because? A. Many neurologic diseases affect one or more of these areas B. Patients are less able to identify other neurologic impairments C. These are the first functions to be affected by neurologic diseases D. Aspects of movement are the most important function of the nervous system
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Correct answer: a Rationale: Many neurologic disorders affect the patient's mobility, strength, and coordination. These problems can alter the patient's usual activity and exercise patterns.
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During neurologic testing, the patient is able to perceive pain elicited by pinprick based on this finding the nurse may omit testing for? A. Position sense B. Patellar reflexes C. Temperature perception D. Heel-to- shin movements
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Correct answer: c Rationale: If pain sensation is intact, assessment of temperature sensation may be omitted because both sensations are transmitted by the same ascending pathways
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A patient's eyes jerk while the patient looks to the left. You will record this finding as? A. Nystagmus B. CN VI palsy C. Oculocephalia D. Ophthalmic dyskenesia
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Correct answer: a Rationale: Nystagmus is defined as fine, rapid jerking movements of the eyes.
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10. The nurse is caring for a patient with peripheral neuropathy who is going to have EMG studies tomorrow morning. The nurse should? A. Ensure the patient has an empty bladder B. Instruct the patient that there is no risk of electric shock C. Ensure the patient has no metallic jewelry or metal fragments D. Instruct the patient that she or he may experience pain during the study
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Correct answer: b Rationale: Electromyography (EMG) is used to assess electrical activity associated with nerves and skeletal muscles. Activity is recorded by insertion of needle electrodes to detect muscle and peripheral nerve disease. The nurse should inform the patient that pain and discomfort are associated with insertion of needles. There is no risk of electric shock with this procedure.
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When assessing a patient with a traumatic brain injury, the nurse notes uncoordinated movement of the extremities. How should the nurse document this assessment? A. Ataxia B. Apraxia C. Anisocoria D. Anosognosia
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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.
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When assessing the accessory nerve, what should the nurse do? A. Assess the gag reflex by stroking the posterior pharynx. B. Ask the patient to shrug the shoulders against resistance. C. Ask the patient to push the tongue to either side against resistance. D. Have the patient say "ah" while visualizing elevation of soft palate.
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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 and to stick out the tongue are used to assess the hypoglossal nerve
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When assessing motor function of a patient admitted with a stroke, the nurse notes mild weakness of the arm demonstrated by downward drifting of the arm. How should the nurse most accurately document this finding? A. Athetosis B. Hypotonia C. Hemiparesis D. Pronator drift
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D. Downward drifting of the arm or pronation of the palm is identified as a 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.
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A patient's sudden onset of hemiplegia has necessitated a computed tomography (CT) of her head. Which assessment should the nurse complete prior to this diagnostic 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.
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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 the majority of patients.
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A patient who has a neurologic disease that affects the pyramidal tract is likely to manifest what sign? A. Impaired muscle movement B. Decreased deep tendon reflexes C. Decreased level of consciousness D. Impaired sensation of touch, pain, and temperature
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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 LOC, impaired reflexes, or decreased sensation.
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How should the nurse most accurately assess the position sense of a patient with a recent traumatic brain injury? A. Ask the patient to close his or her eyes and slowly bring the tips of the index fingers together. B. Ask the patient to stand with the feet together and eyes closed and observe for balance maintainance. C. Ask the patient to close his or her eyes and identify the presence of a common object on the forearm. 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.
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B. The Romberg test is an assessment of position sense in which the patient stands with the feet together and then closes his or her eyes while attempting to maintain balance. The other cited tests of neurologic function do not directly assess position sense.
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The new patient has a diagnosis of frontal lobe dementia. What functional difficulties should the nurse expect in this patient? A. The lack of reflexes B. Endocrine problems C. Higher cognitive function abnormalities D. Respiratory, vasomotor, and cardiac dysfunction
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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.
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Which normal nervous system changes of aging put the geriatric person 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
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B,C,F An older person is at a higher risk for falls because the changes 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. Memory deficits, normal changes of cranial and spinal nerves, and the reticular activation system do not contribute to the increased risk of falls.
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A patient is having a transsphenoidal hypophysectomy. The nurse should provide preoperative patient teaching about what potential deficit as a result of the surgery? A. Increased heart rate B. Loss of coordination C. Impaired swallowing D. Altered sense of smell
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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.
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The nurse is preparing the patient for an electromyography (EMG). What should 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.
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C With an EMG, pain may occur when needles are inserted to record the electrical activity of nerve and skeletal muscle. The patient is tilted on a table during a myelogram. The electroencephalography (EEG) is noninvasive without a danger of electric shock. The magnetoencephalography (MEG) is done with a passive sensor that does not make contact with the patient.
