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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.
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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.
A patient scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the patient for the MRI should prioritize which of the following actions?
- A. Withholding stimulants 24 to 48 hours prior to exam
- B. Removing all metal-containing objects
- C. Instructing the patient to void prior to the MRI
- D. Initiating an IV line for administration of contrast
Correct Answer: B
Rationale: MRI uses strong magnetic fields, making removal of metal objects critical to prevent injury or image distortion. Withholding stimulants applies to EEG, voiding to lumbar puncture, and IV contrast to CT scans.
A 72-year-old man has been brought to his primary care provider by his daughter, who claims that he has been experiencing uncharacteristic lapses in memory. What principle should underlie the nurses assessment and management of this patient?
- A. Loss of short-term memory is normal in older adults, but loss of long-term memory is pathologic.
- B. Lapses in memory in older adults are considered benign unless they have negative consequences.
- C. Gradual increases in confusion accompany the aging process.
- D. Thorough assessment is necessary because changes in cognition are always considered to be pathologic.
Correct Answer: D
Rationale: Cognitive changes in older adults are not assumed normal and require thorough assessment to rule out pathology like dementia. Memory and judgment typically remain intact with aging.
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.
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.