Nokea
The following prescriptions are received for an unconscious patient admitted to the emergency department (ED) with a head injury as result of an automobile accident. Which of the following prescriptions should the nurse question?
- A. Obtain radiographs of the skull and spine.
- B. Prepare the patient for lumbar puncture.
- C. Send for computed tomography (CT) scan.
- D. Perform neurologic checks every 15 minutes.
Correct Answer: B
Rationale: After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure, which could lead to herniation of the brain with lumbar puncture. The other orders are appropriate.
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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.
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.
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.
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 completing a neurological assessment with a patient. Which of the following assessments is the most sensitive indicator of a change in neurological status?
- A. Level of consciousness
- B. Cognition and thought content
- C. Mood and affect
- D. General appearance and behaviour
Correct Answer: A
Rationale: Level of consciousness (LOC) is the most sensitive indicator of changes in neurological status.