Neuro assessment
A nurse is caring for the patient who has had an injury to the hypothalamus. Which intervention is most important for the nurse to implement?
Closely control room temperature
Which statement about the sympathetic system is accurate?
The sympathetic system provides energy for “fight or flight” in stressful situations
What might attribute the slowed knee jerk reflex with which age-related change?
Degeneration of myelin sheath
Describe describes tetraplegia...
Tetraplegia is the newer term for the old term quadriplegia
The nurse interprets the physician’s finding of a grade of 2/5 on the Achilles tendon to mean what has occurred?
Hyperreflexive response for the fifth and sixth cervical nerves
Which action should the nurse take to adequately test the effectiveness for the hypoglossal nerve?
Ask the patient to touch the tip of the tongue to each cheek
What would the following intervention identify as part of a neuro check?
Press down on the patient’s extended arms one at a time while the patient attempts to raise the arm
Assessing muscle strength in a fully conscious patient
Bladder training begins with scheduling the patient’s toileting in what time increment?
Every 2 h
Which sign best indicates that the patient may have experienced a brainstem injury?
Decerebrate posturing
The nurse taps a patient’s knee and observes that the quadriceps muscle reflexively contracts.How should the nurse document this finding?
Patellar reflex 2/5
The nurse is caring for a patient with a head injury. Over a time span of 30 minutes, the nurse observes the following vital signs changes: temperature from 97° to 98° F; pulse from 86 to 78 beats per minute; respirations from 18 to 14 breaths/min; and blood pressure from 140/86 to 150/82. Which action is most important for the nurse to take?
Notify the physician immediately
How is the best way to diagnosis of bacterial meningitis.
Lumbar puncture for cerebrospinal fluid (CSF) analysis and culture
Identify some actions an older adult will take longer to complete due to the loss of neurons in the autonomic nervous system (ANS)
Recuperate from an illness.
Apply brakes to stop a car.
When feeding a patient with dysphagia with a left-sided hemiplegia, how should the nurse position the patient
High Fowler
Which behavior causes the nurse to report a positive Romberg test?
The patient sways from side to side.
The patient is caring for a patient who spontaneously opens his eyes, localizes pain, and carries out confused conversation. The nurse correctly documents which Glasgow Coma Scale (GCS) rating for this patient
13
Identify the assessment findings with The FOUR (Full Outline of UnResponsiveness) tool
Eye response Correct
Motor response Correct
Brainstem response Correct
Respiratory function Correct
What happens with the secretion of norepinephrine and dopamine in aging?
Decreases
Explain multiple sclerosis..
The destruction of the myelin sheath
Which reflex indicates an abnormality in the motor control pathways from the cerebral cortex?
Babinski reflex
When performing a neuro assessment, how should the nurse best evaluate the patient’s thinking?
Ask the patient to add three numbers together in his head
The patient is demonstrating difficulty interpreting questions asked by the nurse. Based on your understanding of aphasia, what type is being manifested?
Receptive
What happens with nerve fibers in aging?
Posterior root nerve fibers and sympathetic nerve fibers decline
Muscular dystrophy can best be described as a what type of disorder?
Genetic or developmental disorder.
The patient who is able to demonstrate an active gag and swallow reflex has exhibited appropriate function of the:
Glossopharyngeal and vagus nerves