62 Questions
The nurse provides care for a client who is comatose and needs to collect motor response data. Which nursing action is appropriate?
Observing the client's response to painful stimuli
A client undergoes a scheduled electroencephalogram (EEG). Which post-procedure activity is most appropriate?
Allow the client to wash hair and rest
What is the primary purpose of the Romberg test?
Assessing equilibrium in a noncomatose client
What does monitoring sensitivity to temperature, touch, and pain assess in a client?
Sensory function of the client
What does a Glasgow Coma Scale (GCS) score of 7 or less indicate?
Comatose state
When should neck examination be avoided?
In case of suspected head or neck injury or trauma
What does unequal, pinpoint, or absent pupillary response indicate?
Neurologic concern
Which cranial nerve is related to the assessment of tongue movement?
XII (hypoglossal nerve)
What is indicated by a GCS score of 9?
Need for emergency attention
What does a lumbar puncture measure in a client presenting post-seizure?
CSF pressure
When is a pretest dose of antihistamine administered?
To clients with allergy history
What does a delayed response to stimulation and drowsiness indicate?
Somnolent state of consciousness
What is documented when the client makes no motor response to stimuli?
Flaccidity
What does nerve conduction studies measure?
Speed of nerve impulse along peripheral nerves
What is an appropriate action to assess level of consciousness?
Stroking the client's hand and moving the client's shoulder
What is used to measure level of consciousness?
Glasgow Coma Scale (GCS)
What is the first action for a client with a brain tumor complaining of a headache upon awakening?
Elevating the head of the bed
What is the primary focus in caring for a client with Parkinson disease?
Maintaining a safe environment
What is the characteristic gait seen in Parkinson disease?
Propulsive gait
What is the important assessment finding in a client with bacterial meningitis?
Cloudy cerebral spinal fluid
What is the purpose of using isotonic normal saline or hypertonic saline solutions in managing increasing ICP?
To decrease brain cell swelling
What is the initial symptom of ALS (Amyotrophic Lateral Sclerosis)?
Muscle weakness of the arms
What is used to manage symptoms of muscle spasticity and rigidity in clients diagnosed with neuromuscular disorders?
Baclofen
What can be beneficial in diagnosing encephalitis secondary to West Nile virus?
Exposure to mosquito bites
What are the normal findings in ICP (Intracranial Pressure)?
Glasgow Coma Scale of 15 and brisk pupil response
What is used to decrease brain cell swelling with increasing ICP?
Isotonic normal saline
What is the priority in the management of symptoms for Bell palsy?
Administering ophthalmic lubricant
What is encouraged in Parkinson disease management?
Establishing a balanced nutrition
What is the priority nursing action during a seizure?
Protect client from injury
Which assessment is important after a lumbar puncture?
Position client flat and provide fluids
What is a characteristic of absence seizures in children?
Brief loss of consciousness and subtle movements
What is a significant sign of rising intracranial pressure in a client with multiple fractures and closed head injury?
Lethargy
What are signs of increasing intracranial pressure in a client with head trauma?
Elevated systolic blood pressure and widening pulse pressure
What is a complication of bacterial meningitis?
Damage to nerves facilitating vision and hearing
What is a priority nursing action for a client with severe myasthenia gravis exacerbation?
Administering medications at exact intervals
What is the nurse assessing when using a safety pin to stroke client's fingers and tube with cold water on arm?
Sensitivity to heat, cold, touch, and pain
Which action is not recommended during a seizure?
Restrain the client
What is not a symptom associated with increasing intracranial pressure?
Stiff neck
What is a complication of bacterial meningitis related to nerve damage?
Damage to nerves facilitating vision and hearing
What is a sign of increasing intracranial pressure in a client with head trauma?
Lethargy
What should the nurse use to remove the paste from the hair after securing an electroencephalogram?
Shampoo
During a neurological examination, what should the nurse assess for to detect neck rigidity?
Moving the head toward both sides
What is the most appropriate response when a client newly diagnosed with multiple sclerosis forgets the name of the covering of axons?
That the covering is called myelin and that it can be discussed further at the next meeting
If the nurse is performing a history and assessment on a client experiencing hearing difficulty, which cranial nerve should be assessed?
VIII
What should the nurse instruct the client to do when a Romberg test is ordered by the physician?
Close eyes and stand erect
Which diagnostic procedure would the nurse anticipate performing first to obtain a thin 'slice' of a muscular body area?
Computed tomography (CT)
What should the nurse note as a concern during a lumbar puncture (LP)?
The cerebrospinal fluid (CSF) is cloudy in nature
How should the nurse respond when a student asks, 'How does someone get super strength in an emergency'?
Sympathetic nervous system
What should the nurse advise the client against before an EEG?
Sedative drugs and caffeine
What should the nurse not measure without healthcare provider's advice?
LOC, heart rate, or pulse rate
Which nervous system regulates energy expenditure in emergency situations?
Sympathetic nervous system
Which cranial nerve is assessed for hearing difficulty?
Cranial nerve VIII
What is used to obtain a thin 'slice' of muscular body area?
CT scan
What is noted as a concern during lumbar puncture?
Cloudy cerebrospinal fluid
What is used to remove EEG paste from hair?
Shampoo
What does the Romberg test involve?
Standing erect with eyes closed
What is explained to the client regarding myelin covering of axons in multiple sclerosis?
Degeneration and scarring of the myelin
What should the nurse assess for in a physical examination of a client with a neurologic disorder?
Neck rigidity
What action should the nurse perform to assess for neck rigidity?
Move head and chin toward chest
What should the nurse provide for the client to review at leisure on a neurological disorder?
Literature
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?
C. VIII
What diagnostic procedure would the nurse anticipate performing first to obtain a thin 'slice' of a muscular body area?
Computed tomography (CT)
Study Notes
Neurological Nursing Interventions and Assessments
- Nurse uses safety pin to stroke client's fingers and tube with cold water on arm to evaluate sensitivity to heat, cold, touch, and pain
- After lumbar puncture, priority is to position client flat and provide adequate fluids to restore cerebrospinal fluid volume
- During a seizure, priority nursing action is to protect client from injury, not to restrain or insert a tongue blade
- Bacterial meningitis complications can lead to damage to nerves facilitating vision and hearing
- Administering medications at exact intervals is a priority nursing action for a client with severe myasthenia gravis exacerbation
- Absence seizures in children are characterized by brief loss of consciousness and subtle movements
- Lethargy is a significant sign of rising intracranial pressure in a client with multiple fractures and closed head injury
- Elevated systolic blood pressure and widening pulse pressure are signs of increasing intracranial pressure in a client with head trauma
- Stiff neck is not a symptom associated with increasing intracranial pressure
- Nursing interventions and assessments focus on protecting clients from injury, positioning for fluid restoration, and administering medications at exact intervals
- Complications of bacterial meningitis can lead to damage to nerves facilitating vision and hearing
- Signs of increasing intracranial pressure include elevated systolic blood pressure and widening pulse pressure, as well as lethargy
Neurological Nursing Assessment and Procedures Summary
- Nurse advises client against sedative drugs and caffeine before EEG
- Nurse should not measure LOC, heart rate, or pulse rate without healthcare provider's advice
- Sympathetic nervous system regulates energy expenditure in emergency situations
- Cranial nerve VIII assessed for hearing difficulty
- CT scan used to obtain thin "slice" of muscular body area
- Cloudy cerebrospinal fluid noted as concern during lumbar puncture
- Shampoo used to remove EEG paste from hair
- Romberg test involves standing erect with eyes closed
- Myelin covering of axons in multiple sclerosis explained to client
- Nurse should assess for neck rigidity in physical examination of client with neurologic disorder
- Nurse should move head and chin toward chest to assess for neck rigidity
- Nurse should provide literature for client to review at leisure on neurological disorder
Test your knowledge of neurological nursing interventions and assessments with this quiz. Explore topics such as sensitivity evaluations, lumbar puncture care, seizure management, bacterial meningitis complications, myasthenia gravis exacerbation, absence seizures, intracranial pressure signs, and nursing priorities.
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