Nokea
The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?
- A. Moving the head toward both sides
- B. Lightly tapping the lower portion of the neck to detect sensation
- C. Moving the head and chin toward the chest
- D. Gently pressing the bones on the neck
Correct Answer: C
Rationale: The neck is examined for stiffness or abnormal position. The presence of rigidity is assessed by moving the head and chin toward the chest. The nurse should not maneuver the neck if a head or neck injury is suspected or known. The neck should also not be maneuvered if trauma to any part of the body is evident. Moving the head toward the sides or pressing the bones on the neck will not help assess for neck rigidity correctly. While assessing for neck rigidity, sensation at the neck area is not assessed.
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The nurse provides care for a client who is comatose and needs to collect motor response data. Which nursing action is appropriate?
- A. Using the Romberg test
- B. Observing the reaction of pupils to light
- C. Observing the client's response to painful stimuli
- D. Monitoring the client's sensitivity to temperature, touch, and pain
Correct Answer: C
Rationale: Assessment of motor function includes muscle movement, size, tone, strength, and coordination. The nurse evaluates motor response in the comatose or unconscious client by administering a painful stimulus to determine the client's response. An appropriate response is for the client to reach toward or withdraw from the stimulus. The Romberg test is used to assess equilibrium in a noncomatose client. Observing the reaction of the client's pupils to light is an oculomotor cranial nerve assessment. Monitoring sensitivity to temperature, touch, and pain assesses the sensory function of the client and not motor response.
The nurse scores the client's level of consciousness (LOC) using the Glasgow Coma Scale. Which score should indicate to the nurse that the client needs emergency attention?
- A. A score of 9
- B. A score of 11
- C. A score of 12
- D. A score of 15
Correct Answer: A
Rationale: A score of 9 indicates that the client needs emergency attention. Scores greater than or equal to 11 are considered within normal range.
The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of which cranial nerve?
- A. II
- B. VI
- C. VIII
- D. XI
Correct Answer: C
Rationale: There are 12 pairs of cranial nerves. Cranial nerve VIII is the vestibulocochlear or auditory nerve responsible for hearing and balance. Cranial nerve II is the optic nerve. Cranial nerve VI is the abducens nerve responsible for eye movement. Cranial nerve XI is the accessory nerve and is involved with head and shoulder movement.
The nurse is caring for a client newly diagnosed with multiple sclerosis who is overwhelmed by learning about the disease. The client indicates understanding that there is a disruption in the covering of axons but does not remember what the covering is called. What should the nurse tell the client?
- A. That it is not necessary to worry about the finer details of the disease.
- B. That because there is so much to learn, there will be another meeting to discuss it again.
- C. That the covering is called myelin and that it can be discussed further at the next meeting.
- D. That the disease process requires more research.
Correct Answer: C
Rationale: Myelin is a fatty substance that covers some axons in the CNS and PNS. The nurse would be most correct in answering the question and then, if the client is tired, following up at the next meeting. It would also be appropriate to provide literature for the client to review at leisure. Discounting the client's need to know information about the disease process is belittling. Telling the client that more research needs to be done discounts the valuable information which is known.
A client presents to the emergency department status postseizure. The health care provider wants to measure CSF pressure. What test might be ordered on this client?
- A. Lumbar puncture
- B. Echoencephalography
- C. Nerve conduction studies
- D. EMG
Correct Answer: A
Rationale: Changes in CSF occur in many neurologic disorders. A lumbar puncture (spinal tap) is performed to obtain samples of CSF from the subarachnoid space for laboratory examination and to measure CSF pressure. Echoencephalography records the electrical impulses generated by the brain. Nerve conduction studies measure the speed with which the nerve impulse travels along the peripheral nerve. Electromyography studies the changes in the electrical potential of muscles and the nerves supplying the muscles.