Neurological Nursing Interventions and Assessments Quiz
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Questions and Answers

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 (correct)
  • Using the Romberg test
  • Monitoring the client's sensitivity to temperature, touch, and pain
  • Observing the reaction of pupils to light

    • A client undergoes a scheduled electroencephalogram (EEG). Which post-procedure activity is most appropriate?

  • Allow the client to wash hair and rest (correct)
  • Provide the client with caffeine-rich drinks
  • Measure the heart and the pulse rate
  • Measure the level of consciousness (LOC) of the client

    • What is the primary purpose of the Romberg test?

  • Assessing motor response in a comatose client
  • Assessing oculomotor cranial nerve function
  • Assessing sensory function of the client
  • Assessing equilibrium in a noncomatose client (correct)

    • What does monitoring sensitivity to temperature, touch, and pain assess in a client?

    <p>Sensory function of the client</p> Signup and view all the answers

    What does a Glasgow Coma Scale (GCS) score of 7 or less indicate?

    <p>Comatose state</p> Signup and view all the answers

    When should neck examination be avoided?

    <p>In case of suspected head or neck injury or trauma</p> Signup and view all the answers

    What does unequal, pinpoint, or absent pupillary response indicate?

    <p>Neurologic concern</p> Signup and view all the answers

    Which cranial nerve is related to the assessment of tongue movement?

    <p>XII (hypoglossal nerve)</p> Signup and view all the answers

    What is indicated by a GCS score of 9?

    <p>Need for emergency attention</p> Signup and view all the answers

    What does a lumbar puncture measure in a client presenting post-seizure?

    <p>CSF pressure</p> Signup and view all the answers

    When is a pretest dose of antihistamine administered?

    <p>To clients with allergy history</p> Signup and view all the answers

    What does a delayed response to stimulation and drowsiness indicate?

    <p>Somnolent state of consciousness</p> Signup and view all the answers

    What is documented when the client makes no motor response to stimuli?

    <p>Flaccidity</p> Signup and view all the answers

    What does nerve conduction studies measure?

    <p>Speed of nerve impulse along peripheral nerves</p> Signup and view all the answers

    What is an appropriate action to assess level of consciousness?

    <p>Stroking the client's hand and moving the client's shoulder</p> Signup and view all the answers

    What is used to measure level of consciousness?

    <p>Glasgow Coma Scale (GCS)</p> Signup and view all the answers

    What is the first action for a client with a brain tumor complaining of a headache upon awakening?

    <p>Elevating the head of the bed</p> Signup and view all the answers

    What is the primary focus in caring for a client with Parkinson disease?

    <p>Maintaining a safe environment</p> Signup and view all the answers

    What is the characteristic gait seen in Parkinson disease?

    <p>Propulsive gait</p> Signup and view all the answers

    What is the important assessment finding in a client with bacterial meningitis?

    <p>Cloudy cerebral spinal fluid</p> Signup and view all the answers

    What is the purpose of using isotonic normal saline or hypertonic saline solutions in managing increasing ICP?

    <p>To decrease brain cell swelling</p> Signup and view all the answers

    What is the initial symptom of ALS (Amyotrophic Lateral Sclerosis)?

    <p>Muscle weakness of the arms</p> Signup and view all the answers

    What is used to manage symptoms of muscle spasticity and rigidity in clients diagnosed with neuromuscular disorders?

    <p>Baclofen</p> Signup and view all the answers

    What can be beneficial in diagnosing encephalitis secondary to West Nile virus?

    <p>Exposure to mosquito bites</p> Signup and view all the answers

    What are the normal findings in ICP (Intracranial Pressure)?

    <p>Glasgow Coma Scale of 15 and brisk pupil response</p> Signup and view all the answers

    What is used to decrease brain cell swelling with increasing ICP?

    <p>Isotonic normal saline</p> Signup and view all the answers

    What is the priority in the management of symptoms for Bell palsy?

    <p>Administering ophthalmic lubricant</p> Signup and view all the answers

    What is encouraged in Parkinson disease management?

    <p>Establishing a balanced nutrition</p> Signup and view all the answers

    What is the priority nursing action during a seizure?

    <p>Protect client from injury</p> Signup and view all the answers

    Which assessment is important after a lumbar puncture?

    <p>Position client flat and provide fluids</p> Signup and view all the answers

    What is a characteristic of absence seizures in children?

    <p>Brief loss of consciousness and subtle movements</p> Signup and view all the answers

    What is a significant sign of rising intracranial pressure in a client with multiple fractures and closed head injury?

    <p>Lethargy</p> Signup and view all the answers

    What are signs of increasing intracranial pressure in a client with head trauma?

    <p>Elevated systolic blood pressure and widening pulse pressure</p> Signup and view all the answers

    What is a complication of bacterial meningitis?

    <p>Damage to nerves facilitating vision and hearing</p> Signup and view all the answers

    What is a priority nursing action for a client with severe myasthenia gravis exacerbation?

    <p>Administering medications at exact intervals</p> Signup and view all the answers

    What is the nurse assessing when using a safety pin to stroke client's fingers and tube with cold water on arm?

    <p>Sensitivity to heat, cold, touch, and pain</p> Signup and view all the answers

    Which action is not recommended during a seizure?

    <p>Restrain the client</p> Signup and view all the answers

    What is not a symptom associated with increasing intracranial pressure?

    <p>Stiff neck</p> Signup and view all the answers

    What is a complication of bacterial meningitis related to nerve damage?

    <p>Damage to nerves facilitating vision and hearing</p> Signup and view all the answers

    What is a sign of increasing intracranial pressure in a client with head trauma?

    <p>Lethargy</p> Signup and view all the answers

    What should the nurse use to remove the paste from the hair after securing an electroencephalogram?

    <p>Shampoo</p> Signup and view all the answers

    During a neurological examination, what should the nurse assess for to detect neck rigidity?

    <p>Moving the head toward both sides</p> Signup and view all the answers

    What is the most appropriate response when a client newly diagnosed with multiple sclerosis forgets the name of the covering of axons?

    <p>That the covering is called myelin and that it can be discussed further at the next meeting</p> Signup and view all the answers

    If the nurse is performing a history and assessment on a client experiencing hearing difficulty, which cranial nerve should be assessed?

    <p>VIII</p> Signup and view all the answers

    What should the nurse instruct the client to do when a Romberg test is ordered by the physician?

    <p>Close eyes and stand erect</p> Signup and view all the answers

    Which diagnostic procedure would the nurse anticipate performing first to obtain a thin 'slice' of a muscular body area?

    <p>Computed tomography (CT)</p> Signup and view all the answers

    What should the nurse note as a concern during a lumbar puncture (LP)?

    <p>The cerebrospinal fluid (CSF) is cloudy in nature</p> Signup and view all the answers

    How should the nurse respond when a student asks, 'How does someone get super strength in an emergency'?

    <p>Sympathetic nervous system</p> Signup and view all the answers

    What should the nurse advise the client against before an EEG?

    <p>Sedative drugs and caffeine</p> Signup and view all the answers

    What should the nurse not measure without healthcare provider's advice?

    <p>LOC, heart rate, or pulse rate</p> Signup and view all the answers

    Which nervous system regulates energy expenditure in emergency situations?

    <p>Sympathetic nervous system</p> Signup and view all the answers

    Which cranial nerve is assessed for hearing difficulty?

    <p>Cranial nerve VIII</p> Signup and view all the answers

    What is used to obtain a thin 'slice' of muscular body area?

    <p>CT scan</p> Signup and view all the answers

    What is noted as a concern during lumbar puncture?

    <p>Cloudy cerebrospinal fluid</p> Signup and view all the answers

    What is used to remove EEG paste from hair?

    <p>Shampoo</p> Signup and view all the answers

    What does the Romberg test involve?

    <p>Standing erect with eyes closed</p> Signup and view all the answers

    What is explained to the client regarding myelin covering of axons in multiple sclerosis?

    <p>Degeneration and scarring of the myelin</p> Signup and view all the answers

    What should the nurse assess for in a physical examination of a client with a neurologic disorder?

    <p>Neck rigidity</p> Signup and view all the answers

    What action should the nurse perform to assess for neck rigidity?

    <p>Move head and chin toward chest</p> Signup and view all the answers

    What should the nurse provide for the client to review at leisure on a neurological disorder?

    <p>Literature</p> Signup and view all the answers

    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?

    <p>C. VIII</p> Signup and view all the answers

    What diagnostic procedure would the nurse anticipate performing first to obtain a thin 'slice' of a muscular body area?

    <p>Computed tomography (CT)</p> Signup and view all the answers

    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

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    Description

    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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