Nokea
The nurse collects data regarding a client's ability to detect sensation in the upper extremity. Which nursing action(s) is appropriate? Select all that apply.
- A. Place a warm cotton ball on the client's arm.
- B. Use a safety pin to stroke the client's fingers.
- C. Use a needle to introduce a prick to the client's skin.
- D. Drag a tube filled with cold water on the client's arm.
- E. Place a tube filled with warm water on the client's hand.
Correct Answer: A,B,D,E
Rationale: The nurse evaluates the extremities for sensitivity to heat, cold, touch, and pain. Various objects can be used by the nurse for this purpose, including cotton balls and tubes filled with hot or cold water. Sharp objects may be used but should not pierce the skin; therefore, it is appropriate for the nurse to stroke the client's fingers with a safety pin but not to prick the skin with a needle.
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The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of which cranial nerve?
- A. II
- B. VI
- C. VIII
- D. XI
Correct Answer: C
Rationale: There are 12 pairs of cranial nerves. Cranial nerve VIII is the vestibulocochlear or auditory nerve responsible for hearing and balance. Cranial nerve II is the optic nerve. Cranial nerve VI is the abducens nerve responsible for eye movement. Cranial nerve XI is the accessory nerve and is involved with head and shoulder movement.
The nurse is instructing a community class when a student asks, 'How does someone get super strength in an emergency?' The nurse should respond by describing the action of the:
- A. musculoskeletal system.
- B. sympathetic nervous system.
- C. parasympathetic nervous system.
- D. endocrine system.
Correct Answer: B
Rationale: The division of the autonomic nervous system called the sympathetic nervous system regulates the expenditure of energy. The neurotransmitters of the sympathetic nervous system are called catecholamines. During an emergency situation or an intensely stressful event, the body adjusts to deliver blood flow and oxygen to the brain, muscles, and lungs that need to react in the situation. The musculoskeletal system benefits from the sympathetic nervous system as the fight-or-flight effects pump blood to the muscles. The parasympathetic nervous system works to conserve body energy not expend it during an emergency. The endocrine system regulates metabolic processes.
A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult that is slowing transmission of the motor neurons, in what would the nurse anticipate a delayed reaction?
- A. Identification of information due to slowed passages of information to brain.
- B. Cognitive ability to understand relayed information.
- C. Processing information transferred from the environment.
- D. Response due to interrupted impulses from the central nervous system
Correct Answer: D
Rationale: The central nervous system is composed of the brain and the spinal cord. Motor neurons transmit impulses from the central nervous system. Slowing transmission in this area would slow the response of transmission leading to a delay in reaction. Sensory neurons transmit impulses from the environment to the central nervous system, allowing identification of a stimulus. Cognitive centers of the brain interpret the information.
The nurse is assessing the assigned client's level of consciousness during morning rounds. The nurse speaks the client's name, strokes the client's hand, and moves the client's shoulder. There is a delay, and then the client states, 'What do you want?' Which level of consciousness should the nurse document?
- A. Conscious
- B. Semicomatose
- C. Somnolent
- D. Stuporous
Correct Answer: C
Rationale: Somnolent or lethargy means that the client is drowsy or sleepy at inappropriate times. This is an improvement from the stuporous state, which includes arousing the client only with vigorous and repeated stimulation. A client that is conscious is alert and responds to stimulation immediately. A client is documented as semicomatose when the client only responds to superficial, relatively mild, painful stimuli.
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.