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Foundations

Exam 5

QuestionAnswer
The Broca's area is the center that is responsible for speech.
A nurse cares for a client who suffered a cerebrovascular accident and demonstrates the inability to speak clearly. The nurse recognizes that injury has occurred to what portion of the brain? Broca's area
The temporal lobe helps with receiving and interpreting impulses from the ear.
influences the ability to read with understanding and is the primary visual receptor center. The occipital lobe
contains the nuclei for the cranial nerves and has centers that control and regulate respiratory function, heart rate and force, and blood pressure. The medulla oblongata
What should the nurse assess to test the function of the frontal lobe? Communication
Assessment of the frontal lobe is done by testing the client’s Communication
To assess the function of the parietal lobe, the nurse should test for tactile sensation.
The function of the temporal lobe is assessed by testing for impulses from the ear.
To assess the function of the occipital lobe, the nurse should test the ability to read.
Many clients, especially the elderly, find it difficult to relax when the nurse attempts to elicit the deep tendon reflexes. What instruction should a nurse give a client who is having trouble relaxing with the testing of the patellar deep tendon reflex? "Place your hands together, lock the fingers, and squeeze
The Glasgow Coma Scale measures the level of consciousness in clients who are at high risk for rapid deterioration of the nervous system. A score of 13 indicates some impairment.
The points associated with the Glascow Coma Scale are determined to assess levels of consciousness and coma. Points are allotted for each of the 3 areas: eye opening, verbal response and motor responses. A score of 13 indicates some impairment.
When testing the leg reflexes, have the client interlock the hands and squeeze.
A client has a disorder of the hypothalamus. The nurse recognizes that this structure is found in which area of the brain? Diencephalon
The diencephalon lies beneath the cerebral hemispheres and consists of the thalamus and hypothalamus.
The cerebrum is divided into the right and left cerebral hemispheres and consists of four lobes (frontal, parietal, temporal, and occipital).
The lobes are composed of a substance known as gray matter, which mediates higher-level functions such as memory, perception, communication, and initiation of voluntary movements.
Located between the cerebral cortex and the spinal cord, the brain stem consists of mostly nerve fibers and has three parts: the midbrain, pons, and medulla oblongata.
Although the cerebellum does not initiate movement, its primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone.
located behind the brain stem and under the cerebrum, also has two hemispheres. The cerebellum,
While assessing the neurologic system of a confused older adult, the nurse observes that the client is unable to recall past events. The nurse suspects that the client may be exhibiting signs of cerebral cortex disorder.
What task should a nurse ask a client to perform to assess the function of cranial nerve XII? Move the tongue from side to side
Asking the client to walk in heel-to-toe fashion helps in assessment of balance.
Asking the client to move the tongue from side to side assesses function of the hypoglossal nerve, cranial nerve XII.
The function of cranial nerve XI can be assessed by asking the client to shrug the shoulders against resistance.
The nurse asks the client to swallow water to assess the function of cranial nerves IX and X.
What is the level of the spinal cord associated with the knee (patellar) deep tendon reflex? L2 to L4
The spinal segments associated with the knee reflex are L2, L3, and L4.
Which of the following assessments is most likely to provide insight into the function of the client's CN VIII? Test the client's hearing for lateralization and bone and air conduction.
frowning and closing the eyes depend on CN VII.
CN VIII is the acoustic nerve; function is thus tested by assessing the client's hearing.
Shoulder shrugging tests CN XI;
is tested by assessing the client's ability to identify smells. CN I
When assessing your patient you note bradykinesia. You would know that this abnormality is caused by damage to what? Basal ganglia system
Damage to this produces changes in muscle tone (most often an increase), disturbances in posture and gait, a slowness or lack of spontaneous and automatic movements termed bradykinesia, and various involuntary movements. the basal ganglia system
Ask the client to stand erect with arms at side and feet together. Note any unsteadiness or swaying. Then with the client in the same body position, ask the client to close the eyes for 20 seconds. Again note any imbalance or swaying. the Romberg test
The nurse is preparing to perform the Romberg test on an adult male client. The nurse should instruct the client to stand erect with arms at the sides and feet together.
The nurse performing an admission assessment on an older adult. What would be an expected finding? Decreased vision
The nurse is assessing an newly admitted client with a seizure disorder. The nurse would asses the client for what? Aura
A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test cranial nerve I. Which of the following would the nurse do? Ask the client to identify scents
Using the Snellen chart tests cranial nerve II, the optic nerve.
which nerve would be tested by having the patient occlude one nostril and identify a scent. Cranial nerve I (olfactory)
The Weber's test evaluates cranial nerve VIII (acoustic/vestibulocochlear).
Testing extraocular eye movements evaluates cranial nerve III (oculomotor), cranial nerve IV (trochlear), and cranial nerve VI (abducens).
A nurse observes a client's gait and notes it to be wide-based and staggering. The Romberg test results were positive. The nurse recognizes this as what type of abnormal gait? Cerebellar ataxia
The characteristic abnormality for this disease is the shuffling gait with a stooped over posture and flexion of the hips and knees. Parkinson's disease
presents with the arm flexed and held close to the body while the client drags toe and circles the leg outward and forward. Spastic hemiparesis
is seen when the client lifts the foot and knee high with each step, then slaps the foot hard to the ground. Steppage gait (footddrop)
The nurse is caring for a client in the hospital and identifies the client to be experiencing acute confusion after cardiac surgery. The nurse recognizes this as what? Delirium
a loss of memory amnesia
an acute onset of confusion related to an underlying cause such as medication, disease or traumatic event. Delirium
may be a cause of delirium. hypoxia
Which of the following assessment techniques should the nurse use to determine a client's stereognosis? With the client's eyes closed, place a coin or key in hand and ask him or her to identify the object.
The gag reflex, rise of the uvula, and ability to swallow are tests to assess cranial nerves IX (glossopharyngeal) and X (vagus).
the ability to identify a familiar object by feeling it. It is tested by placing an object in the client's hand for identification while he or she has the eyes closed. Stereognosis
Which tests are appropriate for a nurse to perform to test cranial nerve VIII? Whisper, Rinne, and Weber tests Correct
Clenching the teeth, identifying light touch, and discriminating between sharp and dull stimuli are assessments of cranial nerve V (trigeminal).
which Cranial nerve is associated with the client's ability to hear. The nurse should perform the whisper test and, using the tuning fork, the Rinne and Weber tests for this cranial nerve VIII acoustic/vestibulocochlear nerve,
Asking the client to smile, frown, show teeth, and puff out the cheeks assesses the function of cranial nerve VII (facial).
A patient's patellar reflex is normal for the right side but diminished on the left. How will the nurse document this finding? Right knee +2; Left knee +1
A client presents to the ED after being hit in the face with a baseball. The health care provider orders vision testing to be performed to assess the whether the cranial nerves are intact. The nurse should prepare to test which cranial nerves? optic Oculomotor Abducens Trochlear
The cranial nerves that control motor and sensation of the eyes are II (optic), III (oculomotor), IV (trochlear), and VI (abducens).
The trigeminal is cranial nerve V, which tests the temporal and masseter muscles.
Cranial nerve I is olfactory, which is associated with the client's sense of smell.
nerve contains sensory fibers for taste on posterior third of tongue and sensory fibers of the pharynx that result in the gag reflex when stimulated. glossopharyngeal
When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence? Mental status, cranial nerves, motor/cerebellar, sensory, reflexes The nurse should perform the assessment of the nervous system from a level of higher cerebral integration to a level of lower reflexes.
A client admitted to hospital with onset of right-sided paralysis, slurred speech, & lethargy. client has a history of uncontrolled hypertension, smokes 2 packs of cigarettes daily. the nursing diagnosis that is priority for the client upon admission? Risk for Aspiration Due to the client's decreased mental status and slurred speech, he is at greatest risk for aspiration.
The nurse is assessing the neurologic system of an adult client. To test the client’s motor function of the facial nerve, the nurse should ask the client to purse the lips. When testing motor function ask the client to smile, frown and wrinkle forehead, show teeth, puff out cheeks, and purse the lips.
The nurse asks a patient to flex and extend the right elbow as part of which screening neurologic examination? Motor system
The nurse working in the ED is assessing an intoxicated driver in a motor vehicle crash. the client insists on ambulating to the bathroom. The nurse escorts the client and calls for help while anticipating which abnormal gait? Cerebellar ataxia Cerebellar ataxia, a wide-based gait with staggering and lurching, is often due to alcohol intake or cerebral palsy.
A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment? Coordination
During an assessment of the cranial nerves, a patient tells the nurse of not being able to taste sweet or salty foods. The nurse should focus additional assessment on which cranial nerve? VII Sensory function of the facial nerve includes the taste for salty and sweet substances on the anterior two thirds of the tongue.
The sensory function of the olfactory nerve is the sense of smell.
The sensory function of the trigeminal nerve covers three areas of the face: around the eyes, along the maxilla, and along the mandible.
The nurse is examining a child with severe cerebral palsy. On sudden movement of the child's foot dorsally, a sustained “beating” of the foot against the nurse's hand ensues. What does this represent? Clonus
The symptom that would alert the nurse to a problem with cranial nerve III would be ptosis
a sustained rhythmical “beating” that correlates with CNS disease and hyperreflexia Clonus
a term applied to sensory testing in which one side of a simultaneous, bilateral stimulus is not felt because of damage to the cortex. Extinction
Which of the following assessments is most likely to provide insight into the function of the client's CN VIII? Test the client's hearing for lateralization and bone and air conduction.
Upon reviewing the client's medical record, the nurse finds the client has left ptosis. The nurse would assess the client for what? Drooping of the left eye
involves four elements that must be established to prove that malpractice or negligence has occurred: duty, breach of duty, causation, and damages. Liability
refers to an obligation to use due care (what a reasonably prudent nurse would do) and is defined by the standard of care appropriate for the nurse–patient relationship. Duty
the failure to meet the standard of care. Breach of duty
the actual harm or injury resulting to the patient. Damages
the most difficult element of liability to prove, shows that the failure to meet the standard of care (breach) actually caused the injury. Causation,
Intentional torts include: Assault and battery, defamation of character, invasion of privacy, false imprisonment, fraud
subject to action in a civil court w/damages usually being settled w/money; may be intentional or unintentional torts
A person committing an intentional tort is considered to have knowledge of the permitted legal limits of his or her words or acts.
Unintentional torts are referred to as negligence.
an assault that is carried out and includes willful, angry, and violent or negligent touching of another person’s body or clothes or anything attached to or held by that other person. Battery
a threat or an attempt to make bodily contact with another person without that person’s consent. Assault
Forcibly removing a patient’s clothing, administering an injection after the patient has refused it, and pushing a patient into a chair are all examples of battery.
an intentional tort in which one party makes derogatory remarks about another that diminish the other party’s reputation. is grounds for an award of civil damages. Defamation of character
spoken defamation of character; Slander
written defamation. libel
Unjustified retention or prevention of the movement of another person without proper consent can constitute false imprisonment.
Disclosure of confidential information, such as inappropriately discussing a patient’s problem with a third party, may be construed as invasion of privacy
designed to protect health practitioners when they give aid to people in emergency situations.  Good Samaritan laws
person’s agreement to allow something to happen, such as surgery, based on a full disclosure of risks, benefits, alternatives, and consequences of refusal. Informed consent
Nurses are legally responsible for carrying out the orders of the physician in charge of a patient unless a reasonable person would anticipate the order to lead to injury.
used by health care agencies to document the occurrence of anything out of the ordinary that results in, or has the potential to result in, harm to a patient, employee, or visitor incident report (also called a variance or occurrence report)
The nurse responsible for a potential or actual harmful incident or who witnesses an injury is the one who completes the incident form
disclosure of confidential information, such as inappropriately discussing a patient’s problem with a third party, may be construed as invasion of privacy and may subject the nurse to liability. 
Nurse Practice Acts are an example of statutory laws.
Each state has a Nurse Practice Act that protects the public by broadly defining the legal scope of nursing practice. 
assault and battery, defamation, invasion of privacy, false imprisonment, fraud Intentional torts
willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property. Fraud
an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.  sentinel event
include errors such as surgery performed on the wrong body part or on the wrong patient, leaving a foreign object inside a patient after surgery, or discharging an infant to the wrong person.  never events
serious but preventable surgical errors never events: 
 formation of a blood clot (“thrombus”) in a deep vein deep vein thrombosis (DVT):
 incomplete expansion or collapse of a part of the lungs atelectasis:
 blood clot, foreign body, or air in the circulatory system; plural form is emboli embolus:
 surgery that is recommended but can be omitted or delayed without catastrophe elective surgery:
excessive blood loss due to the escape of blood from blood vessels hemorrhage: 
surgery that must be performed immediately to save the person’s life or a body organ emergency surgery: 
 used for short-term and minimally invasive procedures moderate sedation/analgesia:
 body’s reaction to acute peripheral circulatory failure due to an abnormality of circulatory control or to a loss of circulating fluid shock:
surgery that is not an emergency, but must be done within a reasonably short time frame to preserve health urgent surgery: 
an area often adjacent to the surgical suite designed to provide care for patients recovering from anesthesia or moderate sedation/analgesia postanesthesia care unit (PACU): 
 wide variety of nursing activities carried out before, during, and after surgery perioperative nursing:
the three phases of patient care that include the preoperative, intraoperative, and postoperative phases perioperative phase: 
 inflammation or infection of the lungs pneumonia:
component of the universal protocol, just prior to beginning a surgical procedure, to verify the patient’s identity and the correct surgical site and procedure time-out: 
 inflammation in a vein associated with thrombus formation thrombophlebitis:
also called conscious or procedural sedation, is used for short-term and minimally invasive procedures. Moderate sedation/analgesia,
The three phases of general anesthesia are induction, maintenance, and emergence.
involves the administration of drugs by the inhalation or intravenous (IV) route to produce central nervous system depression. General anesthesia
also called conscious or procedural sedation, is used for short-term and minimally invasive procedures. Moderate sedation/analgesia,
occurs when an anesthetic agent is injected near a nerve or nerve pathway in or around the operative site, inhibiting the transmission of sensory stimuli to central nervous system receptors. Regional anesthesia
is the injection of an anesthetic agent such as lidocaine, bupivacaine, or tetracaine to a specific area of the body. Local anesthesia
may be mixed with the local anesthetic to minimize bleeding by causing local vasoconstriction. Epinephrine
the patient’s voluntary agreement to undergo a particular procedure or treatment (such as surgery). Informed consent
The responsibility for securing this from the patient lies with the person who will perform the procedure. This is usually the physician. informed consent
may sign as a witness, signifying that the patient signed the consent form without coercion and was alert and aware of the act. The nurse
are at a greater risk from surgery than are children and young or middle-aged adults. Infants and older adults
Hearing loss occurring as a person ages is called presbycusis.
involves the deterioration of nerves and structures within the inner ear. Presbycusis
insufficient quantity or quality of stimuli; may result from decreased sensory input or monotonous, unpatterned, and unmeaningful input. Sensory deprivation
excessive stimuli over which a person feels little control; the brain is unable meaningfully to respond to or ignore stimuli. Sensory overload
the experience of being hospitalized quickly results in sensory overload.
Created by: klmd3014