Nokea
The nurse is caring for a patient with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the patients neurologic assessment?
- A. Decreased muscle tone
- B. Flaccid paralysis
- C. Loss of voluntary control of movement
- D. Slow reflexes
Correct Answer: C
Rationale: Upper motor neuron lesions cause spasticity and loss of voluntary movement control due to disrupted corticospinal signals. Decreased tone, flaccid paralysis, and slow reflexes are typical of lower motor neuron lesions.
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The nurse is doing an initial assessment on a patient newly admitted to the unit with a diagnosis of cerebrovascular accident (CVA). The patient has difficulty copying a figure that the nurse has drawn and is diagnosed with visual-receptive aphasia. What brain region is primarily involved in this deficit?
- A. Temporal lobe
- B. Parietal-occipital area
- C. Inferior posterior frontal areas
- D. Posterior frontal area
Correct Answer: B
Rationale: Visual-receptive aphasia, involving difficulty copying figures, is linked to the parietal-occipital area, which integrates visual and spatial processing. Temporal lobe damage affects auditory comprehension, and frontal areas impact expressive speech.
A patient is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this patient, the nurse has the patient stick out her tongue and move it back and forth. What is the nurse assessing?
- A. Function of the hypoglossal nerve
- B. Function of the vagus nerve
- C. Function of the spinal nerve
- D. Function of the trochlear nerve
Correct Answer: A
Rationale: Tongue movement is controlled by the hypoglossal nerve (XII). The vagus nerve affects throat and voice, spinal nerves control body muscles, and the trochlear nerve moves the eye.
A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution?
- A. Hot or cold packs
- B. Analgesics
- C. Anti-inflammatory medications
- D. Whirlpool baths
Correct Answer: A
Rationale: Blunted pain response in older adults increases burn or frostbite risk from hot or cold packs. Medications and whirlpool baths are not directly related to this sensory change.
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.
A patient is currently being stimulated by the parasympathetic nervous system. What effect will this nervous stimulation have on the patients bladder?
- A. The parasympathetic nervous system causes urinary retention.
- B. The parasympathetic nervous system causes bladder spasms.
- C. The parasympathetic nervous system causes urge incontinence.
- D. The parasympathetic nervous system makes the bladder contract.
Correct Answer: D
Rationale: Parasympathetic stimulation contracts the bladder, promoting urination. Retention, spasms, or incontinence are not direct parasympathetic effects.