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The nurse is performing a neurologic assessment of a patient whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the patients level of consciousness (LOC)?
- A. Assess the patients vital signs and correlate these with the patients baselines.
- B. Assess the patients eye opening and response to stimuli.
- C. Document that the patient currently lacks a level of consciousness.
- D. Facilitate diagnostic testing in an effort to obtain objective data.
Correct Answer: B
Rationale: LOC in non-responsive patients is assessed by eye opening and responses to stimuli, per the Glasgow Coma Scale. Vital signs and testing are supplementary, and lack of response doesn't mean no consciousness.
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A trauma patient in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death?
- A. Magnetic resonance imaging (MRI)
- B. Electroencephalography (EEG)
- C. Electromyelography (EMG)
- D. Computed tomography (CT)
Correct Answer: B
Rationale: EEG confirms brain death by showing no electrical activity. MRI, CT, and EMG are not standard for this determination.
The nurse is caring for a patient who exhibits abnormal results of the Weber test and Rinne test. The nurse should suspect dysfunction involving what cranial nerve?
- A. Trigeminal
- B. Acoustic
- C. Hypoglossal
- D. Trochlear
Correct Answer: B
Rationale: The Weber and Rinne tests assess hearing, mediated by cranial nerve VIII (acoustic). Trigeminal affects facial sensation, hypoglossal moves the tongue, and trochlear controls eye movement.
The nursing students are learning how to assess function of cranial nerve VIII. To assess the function of cranial nerve VIII the students would be correct in completing which of the following assessment techniques?
- A. Have the patient identify familiar odors with the eyes closed.
- B. Assess papillary reflex.
- C. Utilize the Snellen chart.
- D. Test for air and bone conduction (Rinne test).
Correct Answer: D
Rationale: The Rinne test assesses hearing, a function of cranial nerve VIII. Odor identification tests cranial nerve I, pupillary reflex tests III, IV, and VI, and the Snellen chart tests II.
Assessment is crucial to the care of patients with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply.
- A. The ability to select mediations for the neurologic dysfunction
- B. Understanding of the tests used to diagnose neurologic disorders
- C. Knowledge of nursing interventions related to assessment and diagnostic testing
- D. Knowledge of the anatomy of the nervous system
- E. The ability to interpret the results of diagnostic tests
Correct Answer: B,C,D
Rationale: Accurate neurologic assessment requires understanding diagnostic tests, nursing interventions, and nervous system anatomy. Medication selection and test interpretation are typically physician responsibilities.
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.