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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.
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Which of the following assessments should the nurse make to test a patient's cerebellar function? (Select all that apply.)
- A. Assess for graphesthesia.
- B. Perform the finger-to-nose test.
- C. Observe arm movement with gait.
- D. Check ability to push against resistance.
- E. Determine ability to sense heat and cold.
Correct Answer: B,C
Rationale: The cerebellum is responsible for coordination and is assessed by looking at the patient's gait and the finger-to-nose test. The other assessments will be used for other parts of the neurological assessment.
The nurse is admitting a patient with a brain stem infarction. Which of the following assessments is priority?
- A. Reflex reaction time
- B. Pupil reaction to light
- C. Level of consciousness
- D. Respiratory rate and rhythm
Correct Answer: D
Rationale: Vital centres that control respiration are located in the medulla, and these are the priority assessments because changes in respiratory function may be life threatening. The other information also will be collected by the nurse, but it is not as urgent.
The charge nurse is observing a novice staff nurse who is assessing a patient with a possible spinal cord lesion for sensation. Which of the following action indicates a need for further teaching about neurological assessment?
- A. The novice nurse asks the patient, 'Does this feel sharp?'
- B. The novice nurse tests for light touch before testing for pain.
- C. The novice nurse has the patient close the eyes during testing.
- D. The novice nurse uses an irregular pattern to test for intact touch.
Correct Answer: A
Rationale: When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate.
After reviewing a patient's cerebrospinal fluid (CSF) analysis, which of the following results is most important for the nurse to communicate to the health care provider?
- A. Specific gravity 1.007
- B. Protein 6.5 g/L
- C. White blood cell (WBC) count 5 x 10^6/L
- D. Glucose 2.5 mmol/L
Correct Answer: B
Rationale: The protein level is high. The specific gravity, WBCs, and glucose values are normal.
The nurse is caring for a patient who is hospitalized with a possible seizure disorder. To determine the cause of the patient's symptoms, the nurse will anticipate the need to teach the patient about which of the following tests?
- A. Cerebral angiography
- B. Evoked potential studies
- C. Electromyography (EMG)
- D. Electroencephalography (EEG)
Correct Answer: D
Rationale: Seizure disorders are usually studied using EEG testing. Evoked potential is used for diagnosing problems with the visual or auditory systems. Cerebral angiography is used to diagnose vascular problems. EMG is used to evaluate electrical innervation to skeletal muscle.