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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.
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A nurse is caring for a patient diagnosed with Mnires disease. While completing a neurologic examination on the patient, the nurse assesses cranial nerve VIII. The nurse would be correct in identifying the function of this nerve as what?
- A. Movement of the tongue
- B. Visual acuity
- C. Sense of smell
- D. Hearing and equilibrium
Correct Answer: D
Rationale: Cranial nerve VIII (acoustic) governs hearing and balance, relevant in Mnires disease. Tongue movement is cranial nerve XII, visual acuity is II, and smell is I.
The nurse educator is reviewing the assessment of cranial nerves. What should the educator identify as the specific instances when cranial nerves should be assessed? Select all that apply.
- A. When a neurogenic bladder develops
- B. When level of consciousness is decreased
- C. With brain stem pathology
- D. In the presence of peripheral nervous system disease
- E. When a spinal reflex is interrupted
Correct Answer: B,C,D
Rationale: Cranial nerve assessment is indicated for altered consciousness, brain stem issues, or peripheral nervous system disease. Neurogenic bladder and spinal reflexes involve spinal, not cranial, nerves.
The nurse is doing an initial assessment on a patient newly admitted to the unit with a diagnosis of cerebrovascular accident (CVA). The patient has difficulty copying a figure that the nurse has drawn and is diagnosed with visual-receptive aphasia. What brain region is primarily involved in this deficit?
- A. Temporal lobe
- B. Parietal-occipital area
- C. Inferior posterior frontal areas
- D. Posterior frontal area
Correct Answer: B
Rationale: Visual-receptive aphasia, involving difficulty copying figures, is linked to the parietal-occipital area, which integrates visual and spatial processing. Temporal lobe damage affects auditory comprehension, and frontal areas impact expressive speech.
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 patient is scheduled for a myelogram and the nurse explains to the patient that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests?
- A. Lumbar puncture
- B. MRI
- C. Cerebral angiography
- D. EEG
Correct Answer: A
Rationale: Myelography involves contrast injection via lumbar puncture, so preparation is similar. MRI, angiography, and EEG have different preparation requirements.