Assessment of Neurological Function Chapter 35 FA Davis Flashcards

Which assessment findings will the nurse recognize as the Cushing’s triad? Select all that apply.

1.Bradycardia

2.Increased blood pressure with widening pulse pressure

3.Decreased level of consciousness with changed Glasgow coma score

4Dysrhythmias

5.Irregular respirations

Which are major ascending tracts of the spinal cord? Select all that apply.

1.Tectospinal tract

2.Fasciculus gracilis

3.Spinoreticular tract

4.Medial reticulospinal tract

5.Posterior spinocerebellar tract

Which assessment would the nurse be most concerned about for the patient with increased intracranial pressure (ICP) following a brain tumor resection?

1.Quarter-sized dried blood on skull dressing

2.Vomiting

3.Low-grade temperature

4.Decreased urine output

Which instruction would the nurse provide a patient who is having a positron emission tomography test?

1.“Lie quiet and still in a dark room during the procedure.”

2.“Report any implanted devices that may contain metal.”

3.“Stay in bed for at least 12 hours after the procedure.”

4“Wash your hair both the night before and day of the test.”

Which diagnostic test is used to diagnose cancer with rapidly dividing cancer cells?

1.Electroencephalogram

2.Computed axial tomography

3.Positron emission tomography

4.Computed tomographic perfusion scan

Which procedure is most effective to diagnose spinal stenosis?

1.X-ray studies

2.Computed tomography (CT)

3.Cerebral angiography

4.Computed tomography angiography

Which noninvasive study is done to assess the skull and spinal column for fractures, compression, stenosis, and malformation, and can identify areas of injury or trauma?

1.Magnetic resonance imaging (MRI)

2.X-ray

3.Electromyography (EMG)

4.Myelogram

Which are the best descriptions of the nucleus pulposus? Select all that apply.

1.Shock absorbers

2.Calloused material

3.Firm

4.Spongy material

5.Fluid

The nurse is teaching about the interventions provided before a cerebral angiography procedure. Which statement made by the student nurse indicates teaching has been effective?

1.“I must advise the patient to be well hydrated and to drink plenty of fluids.”

2.“I must inform the patient that it takes 60 to 120 minutes for the procedure.”

3.“I will maintain pressure on the arterial puncture site for up to 20 minutes.”

4.“I will inform the patient not to worry if he or she feels cold when the IV contrast is administered.”

The nurse is assisting in a lumbar puncture and the spinal fluid is reported to be pink. Which should the nurse question?

1.If the patient has tuberculosis

2.If the procedure was traumatic

3.If the specimen was contaminated

4.If the white blood cells may be elevated

The nurse is performing this assessment and finds it is positive. What could be the neurological condition causing this?

1.Neuropathy

2.Traumatic brain injury

3.Increased intracranial pressure

4.Cerebral infection

Which assessment finding is included in the triad of symptoms referred to as Cushing’s triad?

1.Tachypnea

2.Ptosis

3.Narrowing pulse pressure

4.Bradycardia

Which patient would be at highest risk of encephalopathy due to COVID-19?

1.75-year-old who has a history of stroke.

2.32-year-old who has type 2 diabetes

3.45-year-old who has a history of asthma

4.54-year-old who has high blood pressure

Which structure of the neurological system is fibrous and protects the brain and spinal cord?

1.Meninges

2.Vertebrae

3.Cerebrospinal fluid

4.Blood-brain barrier

Which neurotransmitters are inhibitory? Select all that apply.

1.Acetylcholine

2.Serotonin

3.Dopamine

4.Glutamate

5.Gamma-aminobutyric acid

When calling the patient’s name, if the patient does not respond, which intervention would the nurse perform next?

1.Rub the patient’s sternum

2.Gently shake the patient

3.Raise their voice and call the patient’s name

4.Firmly pinch the patient’s inner arm

Which assessment will likely be the last to demonstrate changes due to increased intracranial pressure (ICP)?

1.Vital signs

2.Motor response

3.Orientation to person, place, and time

4.Verbal response

Which condition is the patient likely experiencing if the glucose level is low in the spinal fluid?

1.Meningitis

2.Guillain-Barre syndrome

3.Hydrocephalus

4.Severe infection

What is anormal finding for the spinal fluid of a lumbar puncture?

1. Cloudy fluid

2. Protein > 50mg/ dL

3. Specific gravity 1.007

4. Pressure 22 mm Hg

The nurse is caring for a patient after stroke who is having difficulty processing visual imformation.which part of the patient's brain is most likely involved?

1. Frontal

2. Parietal

3.Temporal

4.Occipital

The nurse provides home care instructions to a client who has been fitted with a halo traction device. Which instructions would the nurse include on the list? Select all that apply.

1.Eat foods high in protein and calcium.

2.Remember that a clicking sound heard at the pin site is normal.

3.Tighten the ring bolts on the vest with a wrench if they loosen.

4.Each day, check the skin under the vest with a flashlight for breakdown.

5.Check the tightness of the vest by ensuring that one finger can be placed between it and the skin.

6.When getting out of bed, roll onto the side and push up from the mattress with the arms.

Aneurysm precautions are instituted for a hospitalized client with a cerebral aneurysm. Which nursing interventions would the nurse include in the precautions? Select all that apply.

1.Administering stool softeners to the client

2.Limiting the number of visitors and keeping visits short

3.Encouraging restful activities such as listening to quiet music

4.Keeping the client’s room well lit, especially during the daytime hours

5.Encouraging the client to dress in street clothes and shoes every day

6.Urging the client to perform activities of daily living (e.g., bathing and dressing) independently

Which interventions apply in the care of a child who is experiencing a seizure? Select all that apply.

1.Time the seizure.

2.Restrain the child.

3.Stay with the child.

4.Insert an oral airway.

5.Place the child in a supine position.

6.Loosen clothing around the child’s neck.

A client who has had a stroke is experiencing left-sided unilateral neglect syndrome. Which intervention would the nurse include in the plan of care to manage this effect of the stroke?

1.Instructing the client to primarily scan the left side of the environment

2.Encouraging the client to use the right side only because it is the unaffected side

3.Informing the client that it is best to visualize the environment by looking straight ahead as much as possible

4.Moving personal items to the affected side as the client demonstrates ability to compensate for the neglect

An anticholinesterase medication has been prescribed for a client with myasthenia gravis, and the nurse teaches the client how to recognize a cholinergic crisis. Which would the nurse tell the client is a sign/symptom of this type of crisis?

1.Diarrhea

2.Bladder incontinence

3.Absent cough reflex

4.Decreased urine output

A client being treated for a middle ear infection is unable to close the left eye. After an assessment the client is diagnosed with Bell's palsy. Which information would the nurse give to the client?

1.The eye paralysis is permanent.

2.Artificial tears should be instilled into the left eye.

3.It usually takes about 6 months for the disease to resolve.

4.Intravenous corticosteroids are required, along with intensive physical therapy of the facial muscles.