Nokea
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.
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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 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.
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.
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.
The nurse is assessing the assigned client's level of consciousness during morning rounds. The nurse speaks the client's name, strokes the client's hand, and moves the client's shoulder. There is a delay, and then the client states, 'What do you want?' Which level of consciousness should the nurse document?
- A. Conscious
- B. Semicomatose
- C. Somnolent
- D. Stuporous
Correct Answer: C
Rationale: Somnolent or lethargy means that the client is drowsy or sleepy at inappropriate times. This is an improvement from the stuporous state, which includes arousing the client only with vigorous and repeated stimulation. A client that is conscious is alert and responds to stimulation immediately. A client is documented as semicomatose when the client only responds to superficial, relatively mild, painful stimuli.