Nokea
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.
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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 developing a plan of care for a patient with dysfunction of the cerebellum. Which of the following goals of care should the nurse include?
- A. Prevent falls.
- B. Stabilize mood.
- C. Enhance swallowing ability.
- D. Improve short-term memory.
Correct Answer: A
Rationale: Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability.
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.
The nurse notes in the patient's medical history that the patient has a positive Romberg test. Which of the following nursing diagnoses is appropriate?
- A. Acute pain related to physical injury agent (hyper-reflexia and spasm)
- B. Risk for falls as evidenced by impaired mobility
- C. Risk for autonomic dysreflexia as evidenced by spasm
- D. Ineffective thermoregulation related to inactivity
Correct Answer: B
Rationale: A positive Romberg test indicates that the patient has difficulty maintaining balance with the eyes closed. The Romberg does not test for autonomic dysreflexia, thermoregulation, or hyper-reflexia.
The nurse is admitting a patient with a head injury who is acutely confused. Which of the following actions should the nurse take?
- A. Ask family members about the patient's health history.
- B. Ask leading questions to assist in obtaining health data.
- C. Wait until the patient is better oriented to ask questions.
- D. Obtain only the physiologic neurological assessment data.
Correct Answer: A
Rationale: When admitting a patient with confusion, the nurse should obtain health history information from others who have knowledge about the patient's health to obtain accurate data. Waiting until the patient is oriented or obtaining only physiological data will result in incomplete assessment data, this could adversely affect decision-making about treatment. Asking leading questions may result in inaccurate or incomplete information.