ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 36 : Introduction to the Nervous System Questions
Question 1 of 5
A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture?
Correct Answer: D
Rationale: A client who has undergone a lumbar puncture should be positioned flat and given adequate fluids. These measures help restore the cerebrospinal fluid volume extracted from the client and are priority activities. The client is administered antihistamines to manage any allergic reactions that may occur from the test. The nurse should assess the LOC or the pupil response of the client after a lumbar puncture. Parenteral administration of caffeine sodium benzoate may offset cerebral vasodilation.
Question 2 of 5
The nurse is assessing the client's pupils following a sports injury. Which assessment finding(s) indicates a neurologic concern? Select all that apply.
Correct Answer: A,C,D
Rationale: Normal assessment findings include the pupils being equal and reactive to light. Pupils that are unequal, pinpoint in nature, or fail to respond indicate a neurologic impairment.
Question 3 of 5
The nurse collects data regarding a client's ability to detect sensation in the upper extremity. Which nursing action(s) is appropriate? Select all that apply.
Correct Answer: A,B,D,E
Rationale: The nurse evaluates the extremities for sensitivity to heat, cold, touch, and pain. Various objects can be used by the nurse for this purpose, including cotton balls and tubes filled with hot or cold water. Sharp objects may be used but should not pierce the skin; therefore, it is appropriate for the nurse to stroke the client's fingers with a safety pin but not to prick the skin with a needle.
Question 4 of 5
The nurse provides care for a client who is comatose and needs to collect motor response data. Which nursing action is appropriate?
Correct Answer: C
Rationale: Assessment of motor function includes muscle movement, size, tone, strength, and coordination. The nurse evaluates motor response in the comatose or unconscious client by administering a painful stimulus to determine the client's response. An appropriate response is for the client to reach toward or withdraw from the stimulus. The Romberg test is used to assess equilibrium in a noncomatose client. Observing the reaction of the client's pupils to light is an oculomotor cranial nerve assessment. Monitoring sensitivity to temperature, touch, and pain assesses the sensory function of the client and not motor response.
Question 5 of 5
A client undergoes a scheduled electroencephalogram (EEG). Which post-procedure activity is most appropriate?
Correct Answer: C
Rationale: After an EEG, the nurse should ensure rest for the sleep-deprived client and allow the client to wash hair to remove the glue used to affix electrodes to the scalp. The client is advised not to take sedative drugs and caffeine-related drinks before the EEG; therefore, there is no reason to provide the client with them after the test. The nurse should not measure the LOC, the heart rate, or the pulse rate of the client unless advised by the health care provider.