Nokea
The nurse is conducting a focused neurologic assessment. When assessing the patients cranial nerve function, the nurse would include which of the following assessments?
- A. Assessment of hand grip
- B. Assessment of orientation to person, time, and place
- C. Assessment of arm drift
- D. Assessment of gag reflex
Correct Answer: D
Rationale: The gag reflex assesses cranial nerves IX and X. Hand grip and arm drift evaluate motor function, while orientation assesses mental status, not cranial nerves.
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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.
A nurse is caring for a patient diagnosed with Mnires disease. While completing a neurologic examination on the patient, the nurse assesses cranial nerve VIII. The nurse would be correct in identifying the function of this nerve as what?
- A. Movement of the tongue
- B. Visual acuity
- C. Sense of smell
- D. Hearing and equilibrium
Correct Answer: D
Rationale: Cranial nerve VIII (acoustic) governs hearing and balance, relevant in Mnires disease. Tongue movement is cranial nerve XII, visual acuity is II, and smell is I.
A trauma patient was admitted to the ICU with a brain injury. The patient had a change in level of consciousness, increased vital signs, and became diaphoretic and agitated. The nurse should recognize which of the following syndromes as the most plausible cause of these symptoms?
- A. Adrenal crisis
- B. Hypothalamic collapse
- C. Sympathetic storm
- D. Cranial nerve deficit
Correct Answer: C
Rationale: Sympathetic storm, triggered by brain injury, causes altered consciousness, elevated vital signs, diaphoresis, and agitation due to sympathetic overstimulation. Other options do not fully explain these symptoms.
A patient with lower back pain is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should prioritize what action?
- A. Positioning the patient with the head of the bed elevated 45 degrees
- B. Administering IV morphine sulfate to prevent headache
- C. Limiting fluids for the next 12 hours
- D. Helping the patient perform deep breathing and coughing exercises
Correct Answer: A
Rationale: Elevating the head 30-45 degrees post-myelography prevents contrast dye irritation in the brain, reducing headache risk. Fluids are encouraged, morphine is not standard, and breathing exercises are unnecessary.
In the course of a focused neurologic assessment, the nurse is palpating the patients major muscle groups at rest and during passive movement. Data gleaned from this assessment will allow the nurse to describe which of the following aspects of neurologic function?
- A. Muscle dexterity
- B. Muscle tone
- C. Dysfunction of basal ganglia
- D. Motor symmetry
Correct Answer: B
Rationale: Muscle tone is evaluated by palpating muscles at rest and during passive movement. Dexterity, basal ganglia function, and symmetry require different assessments like coordination or side-to-side comparison.