Ignatavicius Ch 41: Assessment of the Nervous System Flashcards
A nurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which action should the nurse take when providing education about newly prescribed medications to this client?
a. Help the client identify each medication by its color.
b. Provide written materials with large print size.
c. Sit on the clients right side and speak into the right ear.
d. Allow the client to use a white board to ask questions.
c. Sit on the clients right side and speak into the right ear.
The temporal lobe contains the auditory center for sound interpretation. The clients hearing will be impaired in the left ear. The nurse should sit on the clients right side and speak into the right ear. The other interventions do not address the clients left temporal lobe damage.
A nurse plans care for a client who has a hypoactive response to a test of deep tendon reflexes. Which intervention should the nurse include in this clients plan of care?
a. Check bath water temperature with a thermometer.
b. Provide the client with assistance when ambulating.
c. Place elastic support hose on the clients legs.
d. Assess the clients feet for wounds each shift.
b. Provide the client with assistance when ambulating.
Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. The nurse should plan to provide the client with ambulation assistance to prevent injury. The other interventions do not address the clients problem.
A nurse teaches an 80-year-old client with diminished touch sensation. Which statement should the nurse include in this clients teaching?
a. Place soft rugs in your bathroom to decrease pain in your feet.
b. Bathe in warm water to increase your circulation.
c. Look at the placement of your feet when walking.
d. Walk barefoot to decrease pressure ulcers from your shoes.
c. Look at the placement of your feet when walking.
Older clients with decreased sensation are at risk of injury from the inability to sense changes in terrain when walking. To compensate for this loss, the client is instructed to look at the placement of her or his feet when walking. Throw rugs can slip and increase fall risk. Bath water that is too warm places the client at risk for thermal injury. The client should wear sturdy shoes for ambulation.
A nurse assesses a clients recent memory. Which client statement confirms that the clients remote memory is intact?
a. A young girl wrapped in a shroud fell asleep on a bed of clouds.
b. I was born on April 3, 1967, in Johnstown Community Hospital.
c. Apple, chair, and pencil are the words you just stated.
d. I ate oatmeal with wheat toast and orange juice for breakfast.
d. I ate oatmeal with wheat toast and orange juice for breakfast.
Asking clients about recent events that can be verified, such as what the client ate for breakfast, assesses the clients recent memory. The clients ability to make up a rhyme tests not memory, but rather a higher level of cognition. Asking clients about certain facts from the past that can be verified assesses remote or long-term memory. Asking the client to repeat words assesses the clients immediate memory.
A nurse assesses a client who demonstrates a positive Rombergs sign with eyes closed but not with eyes open. Which condition does the nurse associate with this finding?
a. Difficulty with proprioception
b. Peripheral motor disorder
c. Impaired cerebellar function
d. Positive pronator drift
a. Difficulty with proprioception
The client who sways with eyes closed (positive Rombergs sign) but not with eyes open most likely has a disorder of proprioception and uses vision to compensate for it. The other options do not describe a positive Rombergs sign.
A nurse asks a client to take deep breaths during an electroencephalography. The client asks, Why are you asking me to do this? How should the nurse respond?
a. Hyperventilation causes vascular dilation of cerebral arteries, which decreases electoral activity in the brain.
b. Deep breathing helps you to relax and allows the electroencephalograph to obtain a better waveform.
c. Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity.
d. Deep breathing will help you to blow off carbon dioxide and decreases intracranial pressures.
c. Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity.
Hyperventilation produces cerebral vasoconstriction and alkalosis, which increases the likelihood of seizure activity. The client is asked to breathe deeply 20 to 30 times for 3 minutes. The other responses are not accurate.
A nurse assesses a client recovering from a cerebral angiography via the clients right femoral artery. Which assessment should the nurse complete?
a. Palpate bilateral lower extremity pulses.
b. Obtain orthostatic blood pressure readings.
c. Perform a funduscopic examination.
d. Assess the gag reflex prior to eating.
a. Palpate bilateral lower extremity pulses.
Cerebral angiography is performed by threading a catheter through the femoral or brachial artery. The extremity is kept immobilized after the procedure. The nurse checks the extremity for adequate circulation by noting skin color and temperature, presence and quality of pulses distal to the injection site, and capillary refill. Clients usually are on bedrest; therefore, orthostatic blood pressure readings cannot be performed. The funduscopic examination would not be affected by cerebral angiography. The client is given analgesics but not conscious sedation; therefore, the clients gag reflex would not be compromised.
A nurse obtains a focused health history for a client who is scheduled for magnetic resonance angiography. Which priority question should the nurse ask before the test?
a. Have you had a recent blood transfusion?
b. Do you have allergies to iodine or shellfish?
c. Are you taking any cardiac medications?
d. Do you currently use oral contraceptives?
b. Do you have allergies to iodine or shellfish?
Allergies to iodine and/or shellfish need to be explored because the client may have a similar reaction to the dye used in the procedure. In some cases, the client may need to be medicated with antihistamines or steroids before the test is given. A recent blood transfusion or current use of cardiac medications or oral contraceptives would not affect the angiography.
A nurse is caring for a client with a history of renal insufficiency who is scheduled for a computed tomography scan of the head with contrast medium. Which priority intervention should the nurse implement?
a. Educate the client about strict bedrest after the procedure.
b. Place an indwelling urinary catheter to closely monitor output.
c. Obtain a prescription for intravenous fluids.
d. Contact the provider to cancel the procedure.
c. Obtain a prescription for intravenous fluids.
If a contrast medium is used, intravenous fluid may be given to promote excretion of the contrast medium. Contrast medium also may act as a diuretic, resulting in the need for fluid replacement. The client will not require bedrest. Although urinary output should be monitored closely, there is no need for an indwelling urinary catheter. There is no need to cancel the procedure as long as actions are taken to protect the kidneys.
A nurse obtains a focused health history for a client who is scheduled for magnetic resonance imaging (MRI). Which condition should alert the nurse to contact the provider and cancel the procedure?
a. Creatine phosphokinase (CPK) of 100 IU/L
b. Atrioventricular graft
c. Blood urea nitrogen (BUN) of 50 mg/dL
d. Internal insulin pump
d. Internal insulin pump
Metal devices such as internal pumps, pacemakers, and prostheses interfere with the accuracy of the image and can become displaced by the magnetic force generated by an MRI procedure. An atrioventricular graft does not contain any metal. CPK and BUN levels have no impact on an MRI procedure.
A nurse teaches a client who is scheduled for a positron emission tomography scan of the brain. Which statement should the nurse include in this clients teaching?
a. Avoid caffeine-containing substances for 12 hours before the test.
b. Drink at least 3 liters of fluid during the first 24 hours after the test.
c. Do not take your cardiac medication the morning of the test.
d. Remove your dentures and any metal before the test begins.
a. Avoid caffeine-containing substances for 12 hours before the test.
Caffeine-containing liquids and foods are central nervous system stimulants and may alter the test results. No contrast is used; therefore, the client does not need to increase fluid intake. The client should take cardiac medications as prescribed. Metal does not have to be removed; this is done for magnetic resonance imaging.
A nurse cares for a client who is experiencing deteriorating neurologic functions. The client states, I am worried I will not be able to care for my young children. How should the nurse respond?
a. Caring for your children is a priority. You may not want to ask for help, but you have to.
b. Our community has resources that may help you with some household tasks so you have energy to care for your children.
c. You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?
d. Give me more information about what worries you, so we can see if we can do something to make adjustments.
d. Give me more information about what worries you, so we can see if we can do something to make adjustments.
Investigate specific concerns about situational or role changes before providing additional information. The nurse should not tell the client what is or is not a priority for him or her. Although community resources may be available, they may not be appropriate for the client. Consulting a psychologist would not be appropriate without obtaining further information from the client related to current concerns.
A nurse plans care for an 83-year-old client who is experiencing age-related sensory perception changes. Which intervention should the nurse include in this clients plan of care?
a. Provide a call button that requires only minimal pressure to activate.
b. Write the date on the clients white board to promote orientation.
c. Ensure that the path to the bathroom is free from equipment.
d. Encourage the client to season food to stimulate nutritional intake.
c. Ensure that the path to the bathroom is free from equipment.
Dementia and confusion are not common phenomena in older adults. However, physical impairment related to illness can be expected. Providing opportunities for hazard-free ambulation will maintain strength and mobility (and ensure safety). Providing a call button, providing the date, and seasoning food do not address the clients impaired sensory perception.
After teaching a client who is scheduled for magnetic resonance imaging (MRI), the nurse assesses the clients understanding. Which client statement indicates a correct understanding of the teaching?
a. I must increase my fluids because of the dye used for the MRI.
b. My urine will be radioactive so I should not share a bathroom.
c. I can return to my usual activities immediately after the MRI.
d. My gag reflex will be tested before I can eat or drink anything.
c. I can return to my usual activities immediately after the MRI.
No postprocedure restrictions are imposed after MRI. The client can return to normal activities after the test is complete. There are no dyes or radioactive materials used for the MRI; therefore, increased fluids are not needed and the clients urine would not be radioactive. The procedure does not impact the clients gag reflex.
A nurse performs an assessment of pain discrimination on an older adult client. The client correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action should the nurse take next?
a. Touch the pin on the same area of the left hand.
b. Contact the provider with the assessment results.
c. Ask the client about current medications.
d. Continue the assessment on the clients feet.
a. Touch the pin on the same area of the left hand.
If testing is begun on the right hand and the client correctly identifies the pain stimulus, the nurse should continue the assessment on the left hand. This is a normal finding and does not need to be reported to the provider, but instead documented in the clients chart. Medications do not need to be assessed in response to this finding. The nurse should assess the left hand prior to assessing the feet.
