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The nurse assists the health care provider (HCP) in completing a lumbar puncture (LP). Which should the nurse note as a concern?
- A. The HCP maintains aseptic procedure.
- B. The pressure is noted to be 90 mm H2O.
- C. The cerebrospinal fluid (CSF) is cloudy in nature.
- D. The HCP administers a drug by intrathecal injection.
Correct Answer: C
Rationale: The CSF is normally clear and colorless; therefore, CSF that is cloudy would be noted by the nurse as a concern. The HCP is correct to maintain aseptic procedure. At 90 mm H2O, the client's CSF fluid pressure falls within normal limits (between 80 and 100 mm H2O). Sometimes the HCP will administer medication via intrathecal injection during an LP, which should not be a cause for concern.
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The nurse provides care for a client with a deteriorating neurologic status. The nurse collects data at the beginning of the shift that reveals a falling blood pressure (BP) and heart rate (HR), and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate?
- A. Flaccidity
- B. Abnormal posture
- C. Weak muscular tone
- D. Decorticate posturing
Correct Answer: A
Rationale: The nurse should document flaccidity when the client makes no motor response to stimuli. Clients with impaired cerebral function manifest abnormal posturing, which is documented by the nurse as either decorticate posturing (decorticate rigidity), a position in which the arms are flexed, fists are clenched, and the legs are extended or decerebrate posturing (decerebrate rigidity), when the extremities are stiff and rigid. Muscle tone is documented using a scale of 0 to 5; therefore, weak muscular tone is not the most appropriate documentation.
The nurse collects neurologic data and determines that the client has significant visual deficits. A brain tumor is considered. Which area of the brain does the nurse consider to be most likely to contain the neurologic deficit?
- A. Frontal
- B. Parietal
- C. Occipital
- D. Temporal
Correct Answer: C
Rationale: The visual receiving area is in the occipital lobe; therefore, this is the area of the brain the nurse determines is affected for the client with significant visual deficits. The frontal lobe contains the written and motor speech areas. The parietal lobe is the primary sensory area of the brain. The temporal lobe is the auditory receiving and association area of the brain, and is responsible for speech comprehension (i.e., Wernicke area).
The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?
- A. Moving the head toward both sides
- B. Lightly tapping the lower portion of the neck to detect sensation
- C. Moving the head and chin toward the chest
- D. Gently pressing the bones on the neck
Correct Answer: C
Rationale: The neck is examined for stiffness or abnormal position. The presence of rigidity is assessed by moving the head and chin toward the chest. The nurse should not maneuver the neck if a head or neck injury is suspected or known. The neck should also not be maneuvered if trauma to any part of the body is evident. Moving the head toward the sides or pressing the bones on the neck will not help assess for neck rigidity correctly. While assessing for neck rigidity, sensation at the neck area is not assessed.
A critical care nurse is documenting the assessment of a client. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. This means that the client:
- A. has an abnormal posture response to stimuli.
- B. is not responding to stimuli.
- C. is hyperresponsive on the left.
- D. is hyporesponsive on the left.
Correct Answer: B
Rationale: Flaccidity is when the client has no motor response to stimuli. Flaccidity is a motor assessment.
Which diagnostic procedure would the nurse anticipate performing first if the goal was to obtain a thin 'slice' of a muscular body area?
- A. Computed tomography (CT)
- B. Magnetic resonance imaging (MRI)
- C. Positron emission tomography (PET)
- D. Single-photon emission computed tomography (SPECT)
Correct Answer: A
Rationale: A computer tomography scan uses x-rays and computer analysis to produce three-dimensional views of cross sections, or 'slices,' of the body. An MRI uses radiofrequency waves to produce images of tissue. PET scans use radioactive substances to examine metabolic activity and organ involvement. SPECT is an imaging tool that examines cerebral blood flow.