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Which a patient who has peripheral nerve dysfunction? of the following information about an older-adult patient is most important for the admitting nurse to report to the patient's health care provider?
- A. Triceps reflex response graded at 1/5
- B. Recent unintended weight loss of 9.1 kg
- C. Patient complaint of persistent difficulty in falling asleep
- D. Orthostatic drop in systolic blood pressure of 10 mm Hg
Correct Answer: B
Rationale: Although changes in appetite are normal with aging, a 9.1 kg weight loss requires further investigation. Orthostatic drops in blood pressure, changes in sleep patterns, and slowing of reflexes are normal changes in aging.
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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 nurse is developing a plan of care for a patient with dysfunction of the cerebellum. Which of the following goals of care should the nurse include?
- A. Prevent falls.
- B. Stabilize mood.
- C. Enhance swallowing ability.
- D. Improve short-term memory.
Correct Answer: A
Rationale: Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability.
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.
Which of the following actions should the nurse implement to assess the functioning of the trigeminal and facial nerves (CN V and VII) in a patient?
- A. Apply a cotton wisp strand to the cornea.
- B. Have the patient read a magazine or book.
- C. Shine a bright light into the patient's pupil.
- D. Check for unilateral drooping of the eyelids.
Correct Answer: A
Rationale: The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to check function of the oculomotor nerve.
Which of the following equipment should the nurse obtain to assess vibration sense in a patient who has peripheral nerve dysfunction?
- A. Electrodes
- B. Tuning fork
- C. Reflex hammer
- D. Goniometer
Correct Answer: B
Rationale: Vibration sense is tested by touching the patient with a vibrating tuning fork. The other equipment is needed for testing of pain sensation, reflexes, and joint range of motion.