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The nurse is instructing a community class when a student asks, 'How does someone get super strength in an emergency?' The nurse should respond by describing the action of the:
- A. musculoskeletal system.
- B. sympathetic nervous system.
- C. parasympathetic nervous system.
- D. endocrine system.
Correct Answer: B
Rationale: The division of the autonomic nervous system called the sympathetic nervous system regulates the expenditure of energy. The neurotransmitters of the sympathetic nervous system are called catecholamines. During an emergency situation or an intensely stressful event, the body adjusts to deliver blood flow and oxygen to the brain, muscles, and lungs that need to react in the situation. The musculoskeletal system benefits from the sympathetic nervous system as the fight-or-flight effects pump blood to the muscles. The parasympathetic nervous system works to conserve body energy not expend it during an emergency. The endocrine system regulates metabolic processes.
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The nurse assists the health care provider (HCP) in completing a lumbar puncture (LP). Which should the nurse note as a concern?
- A. The HCP maintains aseptic procedure.
- B. The pressure is noted to be 90 mm H2O.
- C. The cerebrospinal fluid (CSF) is cloudy in nature.
- D. The HCP administers a drug by intrathecal injection.
Correct Answer: C
Rationale: The CSF is normally clear and colorless; therefore, CSF that is cloudy would be noted by the nurse as a concern. The HCP is correct to maintain aseptic procedure. At 90 mm H2O, the client's CSF fluid pressure falls within normal limits (between 80 and 100 mm H2O). Sometimes the HCP will administer medication via intrathecal injection during an LP, which should not be a cause for concern.
A critical care nurse is documenting the assessment of a client. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. This means that the client:
- A. has an abnormal posture response to stimuli.
- B. is not responding to stimuli.
- C. is hyperresponsive on the left.
- D. is hyporesponsive on the left.
Correct Answer: B
Rationale: Flaccidity is when the client has no motor response to stimuli. Flaccidity is a motor assessment.
Which neurons transmit impulses from the CNS?
- A. Sensory
- B. Neurilemma
- C. Dendrites
- D. Motor
Correct Answer: D
Rationale: Neurons are either sensory or motor. Sensory neurons transmit impulses to the CNS; motor neurons transmit impulses from the CNS. A membranous sheath called the neurilemma covers the myelin of axons in peripheral nerves. Dendrites are nerve fibers.
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.
A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture?
- A. Administer antihistamines to the client.
- B. Provide adequate caffeine-rich drinks to the client.
- C. Leave the client to rest and do not perform any assessments.
- D. Position the client flat as directed.
Correct Answer: D
Rationale: A client who has undergone a lumbar puncture should be positioned flat and given adequate fluids. These measures help restore the cerebrospinal fluid volume extracted from the client and are priority activities. The client is administered antihistamines to manage any allergic reactions that may occur from the test. The nurse should assess the LOC or the pupil response of the client after a lumbar puncture. Parenteral administration of caffeine sodium benzoate may offset cerebral vasodilation.