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The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm?
- A. Myelogram
- B. Electroencephalogram
- C. Echoencephalography
- D. Cerebral angiography
Correct Answer: D
Rationale: The nurse would anticipate a cerebral angiography, which detects distortion of the cerebral arteries and veins. A myelogram detects abnormalities of the spinal canal. An electroencephalogram records electrical impulses of the brain. An echoencephalography is an ultrasound of the structures of the brain.
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The nurse is caring for a client with a significant allergy history to various medications and shellfish. Because the client needs to have a diagnostic study with contrast, which medication classification is anticipated?
- A. Bronchodilator
- B. Antihistamine
- C. Cardiotonic
- D. Antibiotic
Correct Answer: B
Rationale: Clients with an allergy history are administered a pretest dose of an antihistamine. Antihistamines block histamine receptors and reduce the manifestations of an allergic reaction. The other options are not administered in the pretest period.
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.
Which neurons transmit impulses from the CNS?
- A. Sensory
- B. Neurilemma
- C. Dendrites
- D. Motor
Correct Answer: D
Rationale: Neurons are either sensory or motor. Sensory neurons transmit impulses to the CNS; motor neurons transmit impulses from the CNS. A membranous sheath called the neurilemma covers the myelin of axons in peripheral nerves. Dendrites are nerve fibers.
The nurse collects data regarding a client's ability to detect sensation in the upper extremity. Which nursing action(s) is appropriate? Select all that apply.
- A. Place a warm cotton ball on the client's arm.
- B. Use a safety pin to stroke the client's fingers.
- C. Use a needle to introduce a prick to the client's skin.
- D. Drag a tube filled with cold water on the client's arm.
- E. Place a tube filled with warm water on the client's hand.
Correct Answer: A,B,D,E
Rationale: The nurse evaluates the extremities for sensitivity to heat, cold, touch, and pain. Various objects can be used by the nurse for this purpose, including cotton balls and tubes filled with hot or cold water. Sharp objects may be used but should not pierce the skin; therefore, it is appropriate for the nurse to stroke the client's fingers with a safety pin but not to prick the skin with a needle.
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.