Cranial
Nerves
Nerves
Which CN is being tested with tongue protrusion?
CN XII Hypoglossal
When the patient stands with their feet close together and eyes closed and they sway or fall, what would the nurse document?
Positive Romberg test
This should be clear, odorless, free of red blood cells. Contains, protein, glucose, has a specific gravity of 1.007 and pH of 7.35
Cerebral Spinal Fluid
What would the nurse assess the patient for following a lumbar puncture?
Headache (spinal headache)
What nerve is being assessed when the nurse ask the patient to close 1 nostril at a time and identify and odor
Olfactory
The nurse would use the heel-to-shin test to assess for what abnormality?
Lack of coordination
During a neurologic assessment of the older adult, what would the nurse determine is an effect of aging on the neurologic system
A. Absent deep tendon reflexes
B. Below average intelligence score
C. Decreased sensation of touch and temperature
D. Decreased frequency of spontaneous awakening
C. Decreased sensation of touch and temperature
Electrical activity of brain recorded using scalp electrodes. Evaluates seizure disorders, cerebral diseases, brain injury, brain death.
Electroencephalography (EEG)
What neurologic diagnostic test has the highest risk for complications and requires the nurse to frequently monitor neurologic and vital signs following the procedure?
Cerebral angiography
When the nurse ask the patient to raise their eyebrows, close their eyes tightly, purse lips, and draw back corners of the mouth in an exaggerated smile and frown, she is assessing?
VII Facial nerve
The nurse observes When the patient holds both arms fully extended at shoulder level in front of him with palms upward and eyes closed
Pronator drift
When assessing the muscle strength of an older adult, the nurse cannot compare the findings with those of a younger adult because
a. nutrition status is better in young adults.
b. muscle tone and strength decrease in older adults.
c. muscle strength should be the same for all adults.
d. most young adults exercise more than older adults.
B. Muscle tone and strength decrease in older adults
This study conisist of serial xray visualization of intracranial and extracranial blood vessels, is done to detect, vascular lesions, aneurysms, hematomas and brain tumors.
Nursing Responsibilities- Before:assess for stroke risk. During: warn the patient of contrast dye. After: monitor for neurologic signs and VS every 15-30min, maintain bedrest, and assess for bleeding
Cerebral angiography
A 30 year old patient has been diagnosed with occipital lobe damage after a car accident. The nurse would expect the patient to need help with which task?
Process visual images
Which CN(s) are involved with oblique eye movements?
CN IV Trochlear
CN VI Abducens
CN III The Optic Nerve
A patient taking a drug that impairs function of the extrapyramidal system may have loss of
a. sensations of pain and temperature.
b. regulation of the autonomic nervous system.
c. integration of somatic and special sensory inputs.
d. automatic movements associated with skeletal muscle activity
D. Automatic movements associated with skeletal muscle activity
Older adults are less able to adapt to extremes temperatures and and more vulnerable to and
Hypothermia and Hyperthermia
X-ray of the spinal cord and vertebral column after injection of contrast medium into subarachnoid space. Used to detect spinal lesions, ruptured disc and spinal tumors
Nursing responsibility-Before: give sedative, have patient empty bladder, tell patient test is performed on tilting table. After: patient should lie still 1-2 hours to prevent spinal headache, encourage fluids, monitor neurologic and VS
Myelogram
The patient is admitted to the ER having difficulty with respiratory, vasomotor, and cardiac function. A problem with which part of the brain may be causing these manifestations?
Medulla
During the neurologic, the patient is unable to hear a ticking watch. What neurologic problem would the nurse identify as the cause?
Damage to the CN VIII Cochlear branch of the Acoustic nerve
True or FalseOlder adults are more likely to have orthostatic hypotension, decreased memory, hearing, vision, balance and coordination, tase, smell, position sense, muscle strength and reaction time
TRUE
The nurse is caring for a patient with peripheral neuropathy who is scheduled for EMG studies tomorrow morning. The nurse should
a. ensure the patient has an empty bladder.
b. instruct the patient about the risk for electric shock.
c. ensure the patient has no metallic jewelry or metal fragments.
d. teach the patient that pain may be experienced during the study.
D. Teach the patient that pain may be experienced during the study
What factors are priorities when taking the history of a patient with a neurologic problem?
A. Avoid suggesting symptoms
B. Include CN assessments as the first assessement
C. Mental status must be accurately assessed to ensure that the reported history is factual
D. Do a focused assessment of the neurologic system, as other body systems wont be affected
E. The mode of onset and course of illness are especially important aspects of the nursing history
A, C, E