Nokea
The nurse is admitting a patient to the unit who is diagnosed with a lower motor neuron lesion. What entry in the patients electronic record is most consistent with this diagnosis?
- A. Patient exhibits increased muscle tone.
- B. Patient demonstrates normal muscle structure with no evidence of atrophy.
- C. Patient demonstrates hyperactive deep tendon reflexes.
- D. Patient demonstrates an absence of deep tendon reflexes.
Correct Answer: D
Rationale: Lower motor neuron lesions result in flaccid paralysis, muscle atrophy, and absent deep tendon reflexes due to disrupted nerve supply to muscles. Increased tone and hyperactive reflexes indicate upper motor neuron issues.
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The nurse educator is reviewing the assessment of cranial nerves. What should the educator identify as the specific instances when cranial nerves should be assessed? Select all that apply.
- A. When a neurogenic bladder develops
- B. When level of consciousness is decreased
- C. With brain stem pathology
- D. In the presence of peripheral nervous system disease
- E. When a spinal reflex is interrupted
Correct Answer: B,C,D
Rationale: Cranial nerve assessment is indicated for altered consciousness, brain stem issues, or peripheral nervous system disease. Neurogenic bladder and spinal reflexes involve spinal, not cranial, nerves.
A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, agerelated changes. Of what phenomenon should the nurse be aware?
- A. Hyperactive deep tendon reflexes
- B. Reduction in cerebral blood flow
- C. Increased cerebral metabolism
- D. Hypersensitivity to painful stimuli
Correct Answer: B
Rationale: Aging reduces cerebral blood flow, impacting neurologic function. Deep tendon reflexes may decrease, cerebral metabolism declines, and pain sensitivity often diminishes in older adults.
A patient is scheduled for CT scanning of the head because of recent onset of neurologic deficits. What should the nurse tell the patient in preparation for this test?
- A. No metal objects can enter the procedure room.
- B. You need to fast for 8 hours prior to the test.
- C. You will need to lie still throughout the procedure.
- D. There will be a lot of noise during the test.
Correct Answer: C
Rationale: Lying still during a CT scan ensures clear images. Metal and noise concerns apply to MRI, and fasting is not required for a head CT.
The nurse has admitted a new patient to the unit. One of the patients admitting orders is for an adrenergic medication. The nurse knows that this medication will have what effect on the circulatory system?
- A. Thin, watery saliva
- B. Increased heart rate
- C. Decreased BP
- D. Constricted bronchioles
Correct Answer: B
Rationale: Adrenergic medications stimulate the sympathetic nervous system, increasing heart rate and force. Thin saliva and decreased BP are parasympathetic effects, while bronchodilation, not constriction, occurs.
A patient is scheduled for a myelogram and the nurse explains to the patient that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests?
- A. Lumbar puncture
- B. MRI
- C. Cerebral angiography
- D. EEG
Correct Answer: A
Rationale: Myelography involves contrast injection via lumbar puncture, so preparation is similar. MRI, angiography, and EEG have different preparation requirements.