You're Getting On My Nerves
The patient is having difficulty moving their tongue. What cranial nerve could be impaired on this patient?
a. Accessory (CN XI)
b. Hypoglossal (CN XII)
c. Trochlear (CN IV)
d. Abducens (CN VI)
b. Hypoglossal (CN XII)
Hypoglossal Nerve controls movement of the tongue.
What assessments are included in the Glasgow Coma Scale? (Select all that apply)
a. Eye opening
b. Respiration
c. Brainstem reflexes
d. Motor Response
e. Verbal Response
a. Eye opening
e. Verbal Response
d. Motor Response
A patient has returned from having a CT scan with contrast. Which of the following should be a priority in the hours after the scan?
a. Ambulation
b. Drinking fluids
c. Turning side to side
d. Coughing and deep breathing
b. Drinking fluids
What interventions can help prevent aspiration in a post-stroke patient with dysphagia? (select all that apply)
1. Ensure that the patient is fully alert before feeding.
2. Place patient in high-fowlers position or chair for meals.
3. Use straws for thin liquids
4. Use a thickening agent
5. Place food on affected side of mouth.
1. Ensure that the patient is fully alert before feeding.
2. Place patient in high-fowlers position or chair for meals.
4. Use a thickening agent
The parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder. The nurse bases the response on the understanding that cerebral palsy is which type of condition?
a. An infectious disease of the CNS.
b. An inflammation of the brain as a result of a viral illness.
c. A congenital condition that results in moderate to severe retardation.
d. A chronic disability characterized by impaired muscle movement and posture.
d. A chronic disability characterized by impaired muscle movement and posture.
Your patient has been diagnosed with Covid-19. Your patient complains that they have lost their sense of smell. You know that Covid can affect which cranial nerve?
a. CN II
b. CN VII
c. CN I
d. CN IX
c. CN I
Olfactory nerve controls sense of smell
When performing a neurologic assessment, which of the following is a symptom of increasing intracranial pressure that the nurse should immediately to the primary care provider?
a. Constricted pupils
b. Decreasing level of consciousness
c. Narrowing pulse pressure
d. Bradypnea
b. Decreasing level of consciousness
A patient is admitted following a T4 spinal injury. When taking morning vital signs, the nurse notes that the patient appears restless and that blood pressure is elevated. Which of the following actions by the nurse is appropriate?
a. Recheck the patient's blood pressure in 30 minutes.
b. No action is necessary. This is an expected finding.
c. Check for a full bladder or bowel.
d. Encourage the patient to express any anxiety.
c. Check for a full bladder or bowel.
Increased BP sign of Autonomic dysreflexia
Which is the best method for the nurse to use to communicate with the patient experiencing receptive aphasia?
a. Be patient as the patient tries to speak.
b. Listen carefully, while making eye contact
c. Speak loudly toward the patient's good side.
d. Use gestures, standing where the patient can see.
d. Use gestures, standing where the patient can see.
The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. During data collection about the child, the nurse expects to note which characteristic of this type of posturing?
a. Flaccid paralysis of all extremities
b. Adduction of the arms at the shoulders
c. Rigid extension and pronation of the arms and legs.
d. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities.
c. Rigid extension and pronation of the arms and legs.
You are assessing your patient's pupillary response. Which cranial nerve are your testing?
a. CN II
b. CN III
c. CN IV
d. CN I
b. CN III
Oculomotor nerve controls constriction of pupil for bright light and near vision.
The client is recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which activity?
a. Blowing the nose
b. Isometric exercises'
c. Coughing vigorously
d. Exhaling during repositioning
d. Exhaling during repositioning
The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The lease appropriate measure to minimize the risk of autonomic dysreflexia is which action?
a. Strictly adhering to a bowel retraining program
b. Keeping the linen wrinkle-free under the client
c. Avoiding unnecessary pressure on the lower limbs.
d. Limiting bladder catheterization to once every 12 hours.
d. Limiting bladder catheterization to once every 12 hours.
How soon after symptom onset must a person who is having a stroke receive thrombolytic therapy?
a. 30 min
b. 1 hr
c. 2 hrs
d. 4.5 hrs.
d. 4.5 hrs.
The client with myasthenia gravis is suspected of having cholinergic crisis. Which sign/symptom indicates this crisis is taking place?
a. Ataxia
b. Mouth Sores
c. Hypothermia
d. Hypertension
d. Hypertension
You are assessing your patient and notice that their smile is asymmetrical. Which CN can be affected?
a. CN VIII
b. CN I
c. CN VII
d. CN IX
c. CN VII
Facial nerve contracts facial muscles for frowning, smiling and wrinkling forehead.
The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid meets which criteria?
a. Is grossly bloody in appearance and has a pH of 6.
b. Clumps together on the dressing and has a pH of 7.
c. Is clear in appearance and tests negative for glucose.
d. Separates into concentric rings and tests positive for glucose.
d. Separates into concentric rings and tests positive for glucose.
(CSF) drainage will separate into bloody and yellow concentric rings on dressing material, known as the halo sign. It also tests positive for glucose.
The client is having a lumbar puncture performed. The nurse should place the client in which position for the procedure?
a. Supine, in semi-fowlers.
b. Prone, in slight Trendelenburg's
c. Prone, with a pillow under the abdomen
d. Side-lying, with legs pulled up and chin to the chest.
d. Side-lying, with legs pulled up and chin to the chest.
A nurse is doing an afternoon assessment on a patient transferred to a medical unit from intensive care following a subarachnoid hemorrhage. The patient was alert and oriented during the morning assessment but reported being very tired. Now the patient is difficult to arouse. What action should the nurse take?
a. Let the patient sleep; transferring from the ICU can be very strenuous.
b. Reassess the patient in an hour. If the sleepiness continues, notify the RN.
c. Call the RN immediately
d. Call a code
c. Call the RN immediately
Phenytoin 100mg orally three times daily has been prescribed for a client for seizure control. The nurse reinforces instructions regarding the medication to the client. Which statement by the client indicates an understanding of the instructions?
a. "I will use a soft toothbrush to brush my teeth."
b. "It's all right to break the capsules to make it easier for me to swallow them."
c. "If I forget to take my medication, I can wait until the next dose and eliminate that dose."
d. "If my throat becomes sore, it's a normal effect of the medication and it's nothing to be concerned about."
a. "I will use a soft toothbrush to brush my teeth."
Gingival hyperplasia, bleeding, swelling and tenderness of gums can occur with this medication. Educate your patient on good oral hygiene, gum massage and need for regular dental visits.
Which instruction would the nurse provide for the patient when testing the trigeminal nerve (CN V)?
a. "Stick out your tongue."
b. "Turn your head side to side."
c. "I'm going to shine a light into your eyes and observe your pupils."
d. "Close your eyes and tell me where you feel the cotton touching your face."
d. "Close your eyes and tell me where you feel the cotton touching your face."
Trigeminal nerve controls sensation in face, scalp and teeth.
The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made?
a. "I will use a straw for drinking."
b. "I will drive only during the daytime."
c. "I will use caution because the device alters balance."
d. "I will wash the skin daily under the lamb's wool liner of the vest."
b. "I will drive only during the daytime."
The client should not drive because the device impairs range of vision.
The client with a cervical spine injury has Crutchfild tongs applied in the emergency room. The nurse should perform which essential action when caring for this client?
a. Providing a standard bed frame
b. Removing the weights to reposition the client
c. Removing the weights if the client is uncomfortable.
d. Comparing the amount of prescribed weights with the amount in use.
d. Comparing the amount of prescribed weights with the amount in use.
After administration of of alteplase (tPA), what would be a priority nursing assessment?
a. Dizziness
b. vomiting
c. bleeding
d. nausea
c. bleeding
A child has flu-like symptoms and the parent gives the child medications containing salicylates. What signs/symptoms of Reyes Syndrome would you educate the parent to be aware of?
Reye's Syndrome causes accumulation of ammonia in the blood. If toxic levels accumulate it will cause cerebral manifestations (cerebral edema, ICP), which result in altered behavior, altered LOC, Seizures and coma. Sudden onset of effortless vomiting and altered behavior or altered LOC after a viral illness are common signs/symptoms.