Nokea
A patient has a lesion that affects lower motor neurons. During assessment of the patient's lower extremities, which of the following findings should the nurse expect?
- A. Spasticity
- B. Flaccidity
- C. Loss of sensation
- D. Hyperactive reflexes
Correct Answer: B
Rationale: Because the cell bodies of lower motor neurons are directly affected, a lesion results in flaccidity, loss of muscle tone, and decreased reflexes. Spasticity and hyperactive reflexes are associated with upper motor neuron lesions. Loss of sensation is related to sensory nerve damage, not motor neuron lesions.
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Which of the following assessments should the nurse make to test a patient's cerebellar function? (Select all that apply.)
- A. Assess for graphesthesia.
- B. Perform the finger-to-nose test.
- C. Observe arm movement with gait.
- D. Check ability to push against resistance.
- E. Determine ability to sense heat and cold.
Correct Answer: B,C
Rationale: The cerebellum is responsible for coordination and is assessed by looking at the patient's gait and the finger-to-nose test. The other assessments will be used for other parts of the neurological assessment.
The nurse is completing a neurological assessment with a patient. Which of the following assessments is the most sensitive indicator of a change in neurological status?
- A. Level of consciousness
- B. Cognition and thought content
- C. Mood and affect
- D. General appearance and behaviour
Correct Answer: A
Rationale: Level of consciousness (LOC) is the most sensitive indicator of changes in neurological status.
Which of the following actions should the nurse implement to assess the functioning of the trigeminal and facial nerves (CN V and VII) in a patient?
- A. Apply a cotton wisp strand to the cornea.
- B. Have the patient read a magazine or book.
- C. Shine a bright light into the patient's pupil.
- D. Check for unilateral drooping of the eyelids.
Correct Answer: A
Rationale: The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to check function of the oculomotor nerve.
The nurse is preparing a patient for a lumbar puncture. Which of the following actions should the nurse implement?
- A. Transfer the patient to radiology just before the procedure.
- B. Help the patient to a side lying position before the procedure.
- C. Place the patient on NPO status for 4 hours before the procedure.
- D. Administer a sedative medication 30 minutes before the procedure.
Correct Answer: B
Rationale: For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration.
During the neurological assessment, the patient cooperates with the nurse's directions to grip with the hands and to move the feet but is unable to respond verbally to the nurse's questions. Which of the following diagnoses should the nurse suspect based upon these findings?
- A. A brain stem lesion
- B. A temporal lobe lesion
- C. Injury to the cerebellum
- D. Damage to the frontal lobe
Correct Answer: D
Rationale: Expressive speech is controlled by Broca's area in the frontal lobe. The temporal lobe contains Wernicke's area, which is responsible for receptive speech. The cerebellum and brain stem do not affect higher cognitive functions such as speech.