Nokea
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.
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Neurological testing of the patient indicates impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). Which of the following actions should the nurse include in the plan of care?
- A. Insert an oral airway.
- B. Withhold oral fluid or foods.
- C. Provide highly seasoned foods.
- D. Apply artificial tears every hour.
Correct Answer: B
Rationale: The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex; a patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve.
The nurse is admitting a patient with a head injury who is acutely confused. Which of the following actions should the nurse take?
- A. Ask family members about the patient's health history.
- B. Ask leading questions to assist in obtaining health data.
- C. Wait until the patient is better oriented to ask questions.
- D. Obtain only the physiologic neurological assessment data.
Correct Answer: A
Rationale: When admitting a patient with confusion, the nurse should obtain health history information from others who have knowledge about the patient's health to obtain accurate data. Waiting until the patient is oriented or obtaining only physiological data will result in incomplete assessment data, this could adversely affect decision-making about treatment. Asking leading questions may result in inaccurate or incomplete information.
A patient has a lesion that affects lower motor neurons. During assessment of the patient's lower extremities, which of the following findings should the nurse expect?
- A. Spasticity
- B. Flaccidity
- C. Loss of sensation
- D. Hyperactive reflexes
Correct Answer: B
Rationale: Because the cell bodies of lower motor neurons are directly affected, a lesion results in flaccidity, loss of muscle tone, and decreased reflexes. Spasticity and hyperactive reflexes are associated with upper motor neuron lesions. Loss of sensation is related to sensory nerve damage, not motor neuron lesions.
Metoprolol, a β-adrenergic blocker that inhibits sympathetic nervous system activity, is prescribed for a patient. Which of the following assessments should the nurse monitor?
- A. Dry mouth
- B. Constipation
- C. Slowed pulse
- D. Urinary retention
Correct Answer: C
Rationale: Inhibition of the fight or flight response leads to decreased heart rate. Dry mouth, constipation, and urinary retention are associated with peripheral nervous system blockade.
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.