Nokea
The charge nurse is observing a novice staff nurse who is assessing a patient with a possible spinal cord lesion for sensation. Which of the following action indicates a need for further teaching about neurological assessment?
- A. The novice nurse asks the patient, 'Does this feel sharp?'
- B. The novice nurse tests for light touch before testing for pain.
- C. The novice nurse has the patient close the eyes during testing.
- D. The novice nurse uses an irregular pattern to test for intact touch.
Correct Answer: A
Rationale: When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate.
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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.
Which a patient who has peripheral nerve dysfunction? of the following information about an older-adult patient is most important for the admitting nurse to report to the patient's health care provider?
- A. Triceps reflex response graded at 1/5
- B. Recent unintended weight loss of 9.1 kg
- C. Patient complaint of persistent difficulty in falling asleep
- D. Orthostatic drop in systolic blood pressure of 10 mm Hg
Correct Answer: B
Rationale: Although changes in appetite are normal with aging, a 9.1 kg weight loss requires further investigation. Orthostatic drops in blood pressure, changes in sleep patterns, and slowing of reflexes are normal changes in aging.
After reviewing a patient's cerebrospinal fluid (CSF) analysis, which of the following results is most important for the nurse to communicate to the health care provider?
- A. Specific gravity 1.007
- B. Protein 6.5 g/L
- C. White blood cell (WBC) count 5 x 10^6/L
- D. Glucose 2.5 mmol/L
Correct Answer: B
Rationale: The protein level is high. The specific gravity, WBCs, and glucose values are normal.
Neurological testing of the patient indicates impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). Which of the following actions should the nurse include in the plan of care?
- A. Insert an oral airway.
- B. Withhold oral fluid or foods.
- C. Provide highly seasoned foods.
- D. Apply artificial tears every hour.
Correct Answer: B
Rationale: The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex; a patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve.
Metoprolol, a β-adrenergic blocker that inhibits sympathetic nervous system activity, is prescribed for a patient. Which of the following assessments should the nurse monitor?
- A. Dry mouth
- B. Constipation
- C. Slowed pulse
- D. Urinary retention
Correct Answer: C
Rationale: Inhibition of the fight or flight response leads to decreased heart rate. Dry mouth, constipation, and urinary retention are associated with peripheral nervous system blockade.