Nokea
The nurse caring for an 80 year-old patient knows that she has a pre-existing history of dulled tactile sensation. The nurse should first consider what possible cause for this patients diminished tactile sensation?
- A. Damage to cranial nerve VIII
- B. Adverse medication effects
- C. Age-related neurologic changes
- D. An undiagnosed cerebrovascular accident in early adulthood
Correct Answer: C
Rationale: Aging reduces sensory receptor density, dulling tactile sensation. Cranial nerve VIII affects hearing, medications may cause other effects, and an old CVA is less likely without evidence.
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A patient in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is which of the following?
- A. Cerebellum
- B. Thalamus
- C. Hypothalamus
- D. Midbrain
Correct Answer: C
Rationale: The hypothalamus regulates body temperature via vasoconstriction or vasodilatation. The cerebellum, thalamus, and midbrain do not directly control temperature.
A patient is brought to the ER following a motor vehicle accident in which he sustained head trauma. Preliminary assessment reveals a vision deficit in the patients left eye. The nurse should associate this abnormal finding with trauma to which of the following cerebral lobes?
- A. Temporal
- B. Occipital
- C. Parietal
- D. Frontal
Correct Answer: B
Rationale: The occipital lobe is responsible for visual processing. Trauma to this area can result in vision deficits. The temporal lobe handles auditory functions, the parietal lobe manages sensory integration, and the frontal lobe governs motor and cognitive functions.
An elderly patient is being discharged home. The patient lives alone and has atrophy of his olfactory organs. The nurse tells the patients family that it is essential that the patient have what installed in the home?
- A. Grab bars
- B. Nonslip mats
- C. Baseboard heaters
- D. A smoke detector
Correct Answer: D
Rationale: Olfactory atrophy impairs smell, increasing the risk of missing smoke or gas. A smoke detector is critical for safety. Grab bars and mats address mobility, and heaters are unrelated to olfactory deficits.
A trauma patient was admitted to the ICU with a brain injury. The patient had a change in level of consciousness, increased vital signs, and became diaphoretic and agitated. The nurse should recognize which of the following syndromes as the most plausible cause of these symptoms?
- A. Adrenal crisis
- B. Hypothalamic collapse
- C. Sympathetic storm
- D. Cranial nerve deficit
Correct Answer: C
Rationale: Sympathetic storm, triggered by brain injury, causes altered consciousness, elevated vital signs, diaphoresis, and agitation due to sympathetic overstimulation. Other options do not fully explain these symptoms.
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.