Neuro Review

1. If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with:

Body temperature control.

Digestive system function.

Visual acuity.

Skeletal muscle strength.

Damage to the hypothalamus can disrupt the body's temperature regulation, leading to issues with either hyperthermia or hypothermia. The other options mentioned, such as digestive system function, skeletal muscle strength, and visual acuity, are not primarily controlled by the hypothalamus.

Explanation

Damage to the hypothalamus can disrupt the body's temperature regulation, leading to issues with either hyperthermia or hypothermia. The other options mentioned, such as digestive system function, skeletal muscle strength, and visual acuity, are not primarily controlled by the hypothalamus.

2. A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning?

Ondansetron (Zofran)

Diphenhydramine (Benadryl)

Epinephrine

Lidocaine (Xylocaine)

Lidocaine (Xylocaine) is a local anesthetic that can help reduce the risk of increased intracranial pressure (ICP) during endotracheal suctioning. Epinephrine, Diphenhydramine (Benadryl), and Ondansetron (Zofran) are not typically used for this purpose and could potentially cause an increase in ICP.

Explanation

Lidocaine (Xylocaine) is a local anesthetic that can help reduce the risk of increased intracranial pressure (ICP) during endotracheal suctioning. Epinephrine, Diphenhydramine (Benadryl), and Ondansetron (Zofran) are not typically used for this purpose and could potentially cause an increase in ICP.

3. After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. He’s unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client?

Performing a CT scan

Administering pain medication

Perform a lumbar puncture

Starting IV fluids

Performing a lumbar puncture on a patient with a head injury and nonreactive pupils can increase the risk of brain herniation. Administering pain medication, starting IV fluids, or performing a CT scan are safer initial interventions.

Explanation

Performing a lumbar puncture on a patient with a head injury and nonreactive pupils can increase the risk of brain herniation. Administering pain medication, starting IV fluids, or performing a CT scan are safer initial interventions.

4. The nurse is performing a mental status examination on a male client diagnosed with subdural hematoma. This test assesses for:

Cerebral function

Cardiovascular fitness

Bone density

Muscle strength

A mental status examination assesses the client's cognitive abilities, behavior, and overall cerebral function. It is not related to cardiovascular fitness, muscle strength, or bone density, which are evaluated through different assessments.

Explanation

A mental status examination assesses the client's cognitive abilities, behavior, and overall cerebral function. It is not related to cardiovascular fitness, muscle strength, or bone density, which are evaluated through different assessments.

5. Emergency medical technicians transport a 27-year-old iron worker to the emergency department. They tell the nurse, "He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he's comatose. We intubated him and he's maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual-resuscitation bag." What intervention by the nurse has the highest priority?

Assessing the left leg

Performing a neurological examination

Checking the oxygen saturation levels

Assessing the left chest for contusion

In this scenario, the highest priority intervention for the nurse would be to assess the left leg due to the compound fracture of the left femur. This assessment is crucial to evaluate the extent of the injury and initiate appropriate interventions to prevent further complications.

Explanation

In this scenario, the highest priority intervention for the nurse would be to assess the left leg due to the compound fracture of the left femur. This assessment is crucial to evaluate the extent of the injury and initiate appropriate interventions to prevent further complications.

6. A female client is admitted to the facility for investigation of balance and coordination problems, including possible Ménière's disease. When assessing this client, the nurse expects to note:

Visual disturbances, numbness, and weakness.

Headache, nausea, and rash.

Vertigo, tinnitus, and hearing loss.

Fever, cough, and chest pain.

Ménière’s disease is characterized by the triad of vertigo, tinnitus, and hearing loss. Symptoms such as fever, cough, and chest pain, visual disturbances, numbness, weakness, headache, nausea, and rash are not typically associated with Ménière’s disease.

Explanation

Ménière’s disease is characterized by the triad of vertigo, tinnitus, and hearing loss. Symptoms such as fever, cough, and chest pain, visual disturbances, numbness, weakness, headache, nausea, and rash are not typically associated with Ménière’s disease.

7. The nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction?

Hypotension

Tachycardia

Bradycardia

Respiratory depression

Atropine sulfate is an anticholinergic medication that can lead to tachycardia due to its effect on blocking muscarinic receptors in the heart. This can result in an increase in heart rate.

Explanation

Atropine sulfate is an anticholinergic medication that can lead to tachycardia due to its effect on blocking muscarinic receptors in the heart. This can result in an increase in heart rate.

8. In the intensive care unit, the nurse checks a female client's oculocephalic (doll's eye) response by:

Administering a glucose test

Measuring blood pressure

Shining a bright light into the client's eyes

Introducing ice water into the external auditory canal

Checking a client's oculocephalic (doll's eye) response involves a specific maneuver of introducing ice water into the external auditory canal, which stimulates the vestibular ocular reflex. This maneuver helps in assessing brainstem function and is used to determine if brainstem death has occurred. The other options listed are not relevant to checking the oculocephalic response.

Explanation

Checking a client's oculocephalic (doll's eye) response involves a specific maneuver of introducing ice water into the external auditory canal, which stimulates the vestibular ocular reflex. This maneuver helps in assessing brainstem function and is used to determine if brainstem death has occurred. The other options listed are not relevant to checking the oculocephalic response.

9. A female client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?

Frontal lobe

Cerebellum

Medulla oblongata

Midbrain

Decerebrate posturing is a response to painful stimuli caused by damage to the midbrain, specifically the corticospinal tracts.

Explanation

Decerebrate posturing is a response to painful stimuli caused by damage to the midbrain, specifically the corticospinal tracts.

10. The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?

Call the physician immediately

Administer over-the-counter pain medication

Consult with other nurses on duty

Leave the client alone to rest

A severe headache in a client with a diagnosed cerebral aneurysm could indicate a rupture or worsening of the aneurysm. It is crucial to involve the physician immediately for appropriate evaluation and intervention.

Explanation

A severe headache in a client with a diagnosed cerebral aneurysm could indicate a rupture or worsening of the aneurysm. It is crucial to involve the physician immediately for appropriate evaluation and intervention.

11. During recovery from a cerebrovascular acccident (CVA), a female client is given nothing by mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse aassess the client's swallowing ability once each shift. This assessment evaluates:

Respiratory rate and lung sounds

Muscle strength and range of motion

Cranial nerves IX and X

Heart rate and blood pressure

During swallowing, cranial nerves IX (glossopharyngeal) and X (vagus) play a crucial role in coordinating the movement of the tongue and soft palate. Assessing the function of these nerves helps determine the client's ability to safely swallow liquids without risk of aspiration.

Explanation

During swallowing, cranial nerves IX (glossopharyngeal) and X (vagus) play a crucial role in coordinating the movement of the tongue and soft palate. Assessing the function of these nerves helps determine the client's ability to safely swallow liquids without risk of aspiration.

12. An elderly client is experiencing an alteration in his equilibrium and coordinated muscle movements. The nurse realizes that these functions are controlled by which area of the nervous system?

Hypothalamus

Medulla Oblongata

Frontal Lobe

Cerebellum

The cerebellum is responsible for coordinating muscle movements and maintaining equilibrium. The Medulla Oblongata controls vital functions like breathing and heart rate. The Hypothalamus regulates body temperature, hunger, and thirst. The Frontal Lobe is involved in motor function and decision making.

Explanation

The cerebellum is responsible for coordinating muscle movements and maintaining equilibrium. The Medulla Oblongata controls vital functions like breathing and heart rate. The Hypothalamus regulates body temperature, hunger, and thirst. The Frontal Lobe is involved in motor function and decision making.

13. The nurse wants to assess the function of a client’s accessory nerve (CN XI). Which of the following activities can be done to assess this nerve’s function?

Ask the client to wiggle their ears

Ask the client to touch their nose with their eyes closed

Ask the client to shrug his shoulders

Ask the client to stick out their tongue

Assessing the function of accessory nerve (CN XI) involves testing the ability of the client to perform specific movements that are controlled by this nerve. Asking the client to shrug his shoulders specifically assesses the function of CN XI as it controls the trapezius and sternocleidomastoid muscles responsible for shoulder shrugging.

Explanation

Assessing the function of accessory nerve (CN XI) involves testing the ability of the client to perform specific movements that are controlled by this nerve. Asking the client to shrug his shoulders specifically assesses the function of CN XI as it controls the trapezius and sternocleidomastoid muscles responsible for shoulder shrugging.

14. During an assessment of an adult client’s plantar reflex, the nurse notes a normal response. Which of the following would be considered normal for this client?

Toe curling

Dorsiflexion of the foot

Plantar flexion of the foot

Inversion of the foot

During a plantar reflex assessment, the normal response in an adult client is plantar flexion of the foot. This response is essential for assessing the integrity of the corticospinal tract.

Explanation

During a plantar reflex assessment, the normal response in an adult client is plantar flexion of the foot. This response is essential for assessing the integrity of the corticospinal tract.

15. Which cranial nerve is responsible for severe facial pain while chewing?

Cranial Nerve X Vagus

Cranial Nerve XII Hypoglossal

Cranial Nerve VII Facial

Cranial Nerve V Trigeminal

The correct answer is Cranial Nerve V Trigeminal. This nerve is responsible for transmitting sensory information from the face, including pain signals. The other options do not have the primary role of transmitting facial pain signals.

Explanation

The correct answer is Cranial Nerve V Trigeminal. This nerve is responsible for transmitting sensory information from the face, including pain signals. The other options do not have the primary role of transmitting facial pain signals.