Nokea
A trauma patient in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death?
- A. Magnetic resonance imaging (MRI)
- B. Electroencephalography (EEG)
- C. Electromyelography (EMG)
- D. Computed tomography (CT)
Correct Answer: B
Rationale: EEG confirms brain death by showing no electrical activity. MRI, CT, and EMG are not standard for this determination.
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A patient is brought to the ER following a motor vehicle accident in which he sustained head trauma. Preliminary assessment reveals a vision deficit in the patients left eye. The nurse should associate this abnormal finding with trauma to which of the following cerebral lobes?
- A. Temporal
- B. Occipital
- C. Parietal
- D. Frontal
Correct Answer: B
Rationale: The occipital lobe is responsible for visual processing. Trauma to this area can result in vision deficits. The temporal lobe handles auditory functions, the parietal lobe manages sensory integration, and the frontal lobe governs motor and cognitive functions.
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 gerontologic nurse planning the neurologic assessment of an older adult is considering normal, agerelated changes. Of what phenomenon should the nurse be aware?
- A. Hyperactive deep tendon reflexes
- B. Reduction in cerebral blood flow
- C. Increased cerebral metabolism
- D. Hypersensitivity to painful stimuli
Correct Answer: B
Rationale: Aging reduces cerebral blood flow, impacting neurologic function. Deep tendon reflexes may decrease, cerebral metabolism declines, and pain sensitivity often diminishes in older adults.
Assessment is crucial to the care of patients with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply.
- A. The ability to select mediations for the neurologic dysfunction
- B. Understanding of the tests used to diagnose neurologic disorders
- C. Knowledge of nursing interventions related to assessment and diagnostic testing
- D. Knowledge of the anatomy of the nervous system
- E. The ability to interpret the results of diagnostic tests
Correct Answer: B,C,D
Rationale: Accurate neurologic assessment requires understanding diagnostic tests, nursing interventions, and nervous system anatomy. Medication selection and test interpretation are typically physician responsibilities.
During the performance of the Romberg test, the nurse observes that the patient sways slightly. What is the nurses most appropriate action?
- A. Facilitate a referral to a neurologist.
- B. Reposition the patient supine to ensure safety.
- C. Document successful completion of the assessment.
- D. Follow up by having the patient perform the Rinne test.
Correct Answer: C
Rationale: Slight swaying during the Romberg test is normal and indicates successful completion. Significant swaying prompts further evaluation, but the Rinne test assesses hearing, not balance.