Nokea
The nurse is completing a neurological assessment with a patient. Which of the following assessments is the most sensitive indicator of a change in neurological status?
- A. Level of consciousness
- B. Cognition and thought content
- C. Mood and affect
- D. General appearance and behaviour
Correct Answer: A
Rationale: Level of consciousness (LOC) is the most sensitive indicator of changes in neurological status.
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Which of the following equipment should the nurse obtain to assess vibration sense in a patient who has peripheral nerve dysfunction?
- A. Electrodes
- B. Tuning fork
- C. Reflex hammer
- D. Goniometer
Correct Answer: B
Rationale: Vibration sense is tested by touching the patient with a vibrating tuning fork. The other equipment is needed for testing of pain sensation, reflexes, and joint range of motion.
When caring for a patient who has had cerebral angiography, which of the following nursing actions should be included in the plan of care?
- A. Ask about headache and photophobia.
- B. Keep patient NPO until gag reflex returns.
- C. Check pulse and blood pressure frequently.
- D. Assess orientation to person, place, and time.
Correct Answer: C
Rationale: Since a catheter is inserted into an artery (such as the femoral artery) during cerebral angiography, the nurse should assess for bleeding after this procedure. The other nursing assessments are not necessary after angiography.
Which of the following actions should the nurse implement to assess the functioning of the trigeminal and facial nerves (CN V and VII) in a patient?
- A. Apply a cotton wisp strand to the cornea.
- B. Have the patient read a magazine or book.
- C. Shine a bright light into the patient's pupil.
- D. Check for unilateral drooping of the eyelids.
Correct Answer: A
Rationale: The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to check function of the oculomotor nerve.
The nurse is developing a plan of care for a patient with dysfunction of the cerebellum. Which of the following goals of care should the nurse include?
- A. Prevent falls.
- B. Stabilize mood.
- C. Enhance swallowing ability.
- D. Improve short-term memory.
Correct Answer: A
Rationale: Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability.
The nurse is preparing a patient for a lumbar puncture. Which of the following actions should the nurse implement?
- A. Transfer the patient to radiology just before the procedure.
- B. Help the patient to a side lying position before the procedure.
- C. Place the patient on NPO status for 4 hours before the procedure.
- D. Administer a sedative medication 30 minutes before the procedure.
Correct Answer: B
Rationale: For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration.