Nokea
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.
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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.
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.
The nurse is completing a neurological assessment with a patient. Which of the following assessments is the most sensitive indicator of a change in neurological status?
- A. Level of consciousness
- B. Cognition and thought content
- C. Mood and affect
- D. General appearance and behaviour
Correct Answer: A
Rationale: Level of consciousness (LOC) is the most sensitive indicator of changes in neurological status.
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 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.