Nokea
The critical care nurse is giving end-of-shift report on a client. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate?
- A. Comatose
- B. Somnolence
- C. Stupor
- D. Normal
Correct Answer: A
Rationale: The GSC is used to measure the LOC. The scale consists of three parts: eye opening response, best verbal response, and best motor response. A normal response is 15. A score of 7 or less is considered comatose. Therefore, a score of 6 indicates the client is in a state of coma and not in any other state such as stupor or somnolence. The evaluations are recorded on a graphic sheet where connecting lines show an increase or decrease in the LOC.
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A nurse is noting from a client's neurologic assessment findings that the client's motor impulses are interrupted from the brain to the spinal cord. It also appears that the client lacks sensory impulses from the peripheral sensory neurons to the brain. Which area has the deficit?
- A. Midbrain
- B. Medulla oblongata
- C. Pons
- D. Subarachnoid space
Correct Answer: B
Rationale: The medulla oblongata lies below the pons and transmits motor impulses from the brain to the spinal cord, and sensory impulses from the peripheral sensory neurons to the brain. The pons is part of the brainstem. The midbrain forms the forward part of the brainstem and connects the pons and the cerebellum with the two cerebral hemispheres. The subarachnoid space lies between the pie matter and the arachnoids membrane.
A nurse is working in a neurologist's office. The physician orders a Romberg test. What should the nurse instruct the client to do?
- A. Touch nose with one finger.
- B. Close eyes and stand erect.
- C. Close eyes and discriminate between dull and sharp.
- D. Close eyes and jump on one foot.
Correct Answer: B
Rationale: In the Romberg test, the client stands erect with the feet close together and eyes closed. If the client sways as if to fall, it is considered a positive Romberg test. All of the other options include components of neurologic tests, indicating neurologic deficits and balance.
The nurse is caring for a client newly diagnosed with multiple sclerosis who is overwhelmed by learning about the disease. The client indicates understanding that there is a disruption in the covering of axons but does not remember what the covering is called. What should the nurse tell the client?
- A. That it is not necessary to worry about the finer details of the disease.
- B. That because there is so much to learn, there will be another meeting to discuss it again.
- C. That the covering is called myelin and that it can be discussed further at the next meeting.
- D. That the disease process requires more research.
Correct Answer: C
Rationale: Myelin is a fatty substance that covers some axons in the CNS and PNS. The nurse would be most correct in answering the question and then, if the client is tired, following up at the next meeting. It would also be appropriate to provide literature for the client to review at leisure. Discounting the client's need to know information about the disease process is belittling. Telling the client that more research needs to be done discounts the valuable information which is known.
The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm?
- A. Myelogram
- B. Electroencephalogram
- C. Echoencephalography
- D. Cerebral angiography
Correct Answer: D
Rationale: The nurse would anticipate a cerebral angiography, which detects distortion of the cerebral arteries and veins. A myelogram detects abnormalities of the spinal canal. An electroencephalogram records electrical impulses of the brain. An echoencephalography is an ultrasound of the structures of the brain.
The nurse provides care for a client who is comatose and needs to collect motor response data. Which nursing action is appropriate?
- A. Using the Romberg test
- B. Observing the reaction of pupils to light
- C. Observing the client's response to painful stimuli
- D. Monitoring the client's sensitivity to temperature, touch, and pain
Correct Answer: C
Rationale: Assessment of motor function includes muscle movement, size, tone, strength, and coordination. The nurse evaluates motor response in the comatose or unconscious client by administering a painful stimulus to determine the client's response. An appropriate response is for the client to reach toward or withdraw from the stimulus. The Romberg test is used to assess equilibrium in a noncomatose client. Observing the reaction of the client's pupils to light is an oculomotor cranial nerve assessment. Monitoring sensitivity to temperature, touch, and pain assesses the sensory function of the client and not motor response.