Nokea
A patient in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is which of the following?
- A. Cerebellum
- B. Thalamus
- C. Hypothalamus
- D. Midbrain
Correct Answer: C
Rationale: The hypothalamus regulates body temperature via vasoconstriction or vasodilatation. The cerebellum, thalamus, and midbrain do not directly control temperature.
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The nurse is conducting a focused neurologic assessment. When assessing the patients cranial nerve function, the nurse would include which of the following assessments?
- A. Assessment of hand grip
- B. Assessment of orientation to person, time, and place
- C. Assessment of arm drift
- D. Assessment of gag reflex
Correct Answer: D
Rationale: The gag reflex assesses cranial nerves IX and X. Hand grip and arm drift evaluate motor function, while orientation assesses mental status, not cranial nerves.
A patient is having a fight or flight response after receiving bad news about his prognosis. What affect will this have on the patients sympathetic nervous system?
- A. Constriction of blood vessels in the heart muscle
- B. Constriction of bronchioles
- C. Increase in the secretion of sweat
- D. Constriction of pupils
Correct Answer: C
Rationale: Sympathetic activation during fight or flight increases sweat secretion, dilates heart muscle vessels, bronchodilates, and dilates pupils.
The neurologist is testing the function of a patients cerebellum and basal ganglia. What action will most accurately test these structures?
- A. Have the patient identify the location of a cotton swab on his or her skin with the eyes closed.
- B. Elicit the patients response to a hypothetical problem.
- C. Ask the patient to close his or her eyes and discern between hot and cold stimuli.
- D. Guide the patient through the performance of rapid, alternating movements.
Correct Answer: D
Rationale: Rapid, alternating movements test cerebellar and basal ganglia coordination. Sensory tests assess peripheral nerves, and hypothetical problems evaluate cognition.
A patient is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this patient, the nurse has the patient stick out her tongue and move it back and forth. What is the nurse assessing?
- A. Function of the hypoglossal nerve
- B. Function of the vagus nerve
- C. Function of the spinal nerve
- D. Function of the trochlear nerve
Correct Answer: A
Rationale: Tongue movement is controlled by the hypoglossal nerve (XII). The vagus nerve affects throat and voice, spinal nerves control body muscles, and the trochlear nerve moves the eye.
A nurse is assessing reflexes in a patient with hyperactive reflexes. When the patients foot is abruptly dorsiflexed, it continues to beat two to three times before settling into a resting position. How would the nurse document this finding?
- A. Rigidity
- B. Flaccidity
- C. Clonus
- D. Ataxia
Correct Answer: C
Rationale: Clonus is characterized by rhythmic muscle contractions, such as foot beating after dorsiflexion, indicating hyperactive reflexes. Rigidity is increased muscle tone, flaccidity is lack of tone, and ataxia is uncoordinated movement.