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The nurse provides care for a client with a deteriorating neurologic status. The nurse collects data at the beginning of the shift that reveals a falling blood pressure (BP) and heart rate (HR), and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate?
- A. Flaccidity
- B. Abnormal posture
- C. Weak muscular tone
- D. Decorticate posturing
Correct Answer: A
Rationale: The nurse should document flaccidity when the client makes no motor response to stimuli. Clients with impaired cerebral function manifest abnormal posturing, which is documented by the nurse as either decorticate posturing (decorticate rigidity), a position in which the arms are flexed, fists are clenched, and the legs are extended or decerebrate posturing (decerebrate rigidity), when the extremities are stiff and rigid. Muscle tone is documented using a scale of 0 to 5; therefore, weak muscular tone is not the most appropriate documentation.
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A nurse is working in a neurologist's office. The physician orders a Romberg test. What should the nurse instruct the client to do?
- A. Touch nose with one finger.
- B. Close eyes and stand erect.
- C. Close eyes and discriminate between dull and sharp.
- D. Close eyes and jump on one foot.
Correct Answer: B
Rationale: In the Romberg test, the client stands erect with the feet close together and eyes closed. If the client sways as if to fall, it is considered a positive Romberg test. All of the other options include components of neurologic tests, indicating neurologic deficits and balance.
The nurse is assessing the client's pupils following a sports injury. Which assessment finding(s) indicates a neurologic concern? Select all that apply.
- A. Unequal pupils
- B. Pupil reaction quick
- C. Pinpoint pupils
- D. Absence of pupillary response
- E. Pupil reacts to light
Correct Answer: A,C,D
Rationale: Normal assessment findings include the pupils being equal and reactive to light. Pupils that are unequal, pinpoint in nature, or fail to respond indicate a neurologic impairment.
The nurse collects neurologic data and determines that the client has significant visual deficits. A brain tumor is considered. Which area of the brain does the nurse consider to be most likely to contain the neurologic deficit?
- A. Frontal
- B. Parietal
- C. Occipital
- D. Temporal
Correct Answer: C
Rationale: The visual receiving area is in the occipital lobe; therefore, this is the area of the brain the nurse determines is affected for the client with significant visual deficits. The frontal lobe contains the written and motor speech areas. The parietal lobe is the primary sensory area of the brain. The temporal lobe is the auditory receiving and association area of the brain, and is responsible for speech comprehension (i.e., Wernicke area).
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.
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.