Nokea
A nurse is working in an outpatient studies unit administering neurological tests. The client is surprised that paste is used to secure an electroencephalogram and asks how it will be removed from the hair. With what substance does the nurse reply?
- A. Acetone
- B. A special soap
- C. Shampoo
- D. Warm water
Correct Answer: C
Rationale: Shampoo is used to remove the paste, which attached the electrodes to the head. Acetone is not used on the hair. There is no special soap needed. More than warm water is needed to lift and remove the paste.
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The nurse assists the health care provider (HCP) in completing a lumbar puncture (LP). Which should the nurse note as a concern?
- A. The HCP maintains aseptic procedure.
- B. The pressure is noted to be 90 mm H2O.
- C. The cerebrospinal fluid (CSF) is cloudy in nature.
- D. The HCP administers a drug by intrathecal injection.
Correct Answer: C
Rationale: The CSF is normally clear and colorless; therefore, CSF that is cloudy would be noted by the nurse as a concern. The HCP is correct to maintain aseptic procedure. At 90 mm H2O, the client's CSF fluid pressure falls within normal limits (between 80 and 100 mm H2O). Sometimes the HCP will administer medication via intrathecal injection during an LP, which should not be a cause for concern.
A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult that is slowing transmission of the motor neurons, in what would the nurse anticipate a delayed reaction?
- A. Identification of information due to slowed passages of information to brain.
- B. Cognitive ability to understand relayed information.
- C. Processing information transferred from the environment.
- D. Response due to interrupted impulses from the central nervous system
Correct Answer: D
Rationale: The central nervous system is composed of the brain and the spinal cord. Motor neurons transmit impulses from the central nervous system. Slowing transmission in this area would slow the response of transmission leading to a delay in reaction. Sensory neurons transmit impulses from the environment to the central nervous system, allowing identification of a stimulus. Cognitive centers of the brain interpret the information.
Which neurons transmit impulses from the CNS?
- A. Sensory
- B. Neurilemma
- C. Dendrites
- D. Motor
Correct Answer: D
Rationale: Neurons are either sensory or motor. Sensory neurons transmit impulses to the CNS; motor neurons transmit impulses from the CNS. A membranous sheath called the neurilemma covers the myelin of axons in peripheral nerves. Dendrites are nerve fibers.
The nurse is assessing the assigned client's level of consciousness during morning rounds. The nurse speaks the client's name, strokes the client's hand, and moves the client's shoulder. There is a delay, and then the client states, 'What do you want?' Which level of consciousness should the nurse document?
- A. Conscious
- B. Semicomatose
- C. Somnolent
- D. Stuporous
Correct Answer: C
Rationale: Somnolent or lethargy means that the client is drowsy or sleepy at inappropriate times. This is an improvement from the stuporous state, which includes arousing the client only with vigorous and repeated stimulation. A client that is conscious is alert and responds to stimulation immediately. A client is documented as semicomatose when the client only responds to superficial, relatively mild, painful stimuli.
The nurse is caring for a client who is undergoing single-photon emission computed tomography (SPECT). What is a potential side effect that this client may suffer?
- A. Headache and pain in the neck
- B. Claustrophobia
- C. Allergic reaction to the imaging material
- D. Allergic reaction to radioactive rays
Correct Answer: C
Rationale: SPECT obtains images of the brain after the client intravenously receives radiopharmaceuticals and radioisotopes approximately 1 hour before the test begins. A potential risk of SPECT is the client's allergic reaction to the imaging material. Headache is an aftereffect of a cisternal puncture, and claustrophobia is experienced by clients during a magnetic resonance imaging scan.