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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.
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A client undergoes a scheduled electroencephalogram (EEG). Which post-procedure activity is most appropriate?
- A. Measure the heart and the pulse rate.
- B. Provide the client with caffeine-rich drinks.
- C. Allow the client to wash hair and rest.
- D. Measure the level of consciousness (LOC) of the client.
Correct Answer: C
Rationale: After an EEG, the nurse should ensure rest for the sleep-deprived client and allow the client to wash hair to remove the glue used to affix electrodes to the scalp. The client is advised not to take sedative drugs and caffeine-related drinks before the EEG; therefore, there is no reason to provide the client with them after the test. The nurse should not measure the LOC, the heart rate, or the pulse rate of the client unless advised by the health care provider.
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.
A nurse is working in a neurologist's office. The physician orders a Romberg test. What should the nurse instruct the client to do?
- A. Touch nose with one finger.
- B. Close eyes and stand erect.
- C. Close eyes and discriminate between dull and sharp.
- D. Close eyes and jump on one foot.
Correct Answer: B
Rationale: In the Romberg test, the client stands erect with the feet close together and eyes closed. If the client sways as if to fall, it is considered a positive Romberg test. All of the other options include components of neurologic tests, indicating neurologic deficits and balance.
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 client's pupils following a sports injury. Which assessment finding(s) indicates a neurologic concern? Select all that apply.
- A. Unequal pupils
- B. Pupil reaction quick
- C. Pinpoint pupils
- D. Absence of pupillary response
- E. Pupil reacts to light
Correct Answer: A,C,D
Rationale: Normal assessment findings include the pupils being equal and reactive to light. Pupils that are unequal, pinpoint in nature, or fail to respond indicate a neurologic impairment.