Nursing Neurological Exam (Answers 21-25)

- The catheter for measuring ICP is inserted through a burr hole into a lateral ventricle of the cerebrum, thereby creating a risk of infection. Coma, high blood pressure, and apnea are late signs of increased ICP.

22) A
- During an acute crisis, the examiner checks the corneal reflex response to rapidly assess brain stem function. Other components of the brief initial neurologic assessment usually include level of consciousness, pupillary response, and motor response in all arms and legs. If appropriate and if time permits, the nurse also may assess sensory responses of the arms and legs. Emergency assessment doesn't include fundus examination unless the client has sustained direct eye trauma. The client shouldn't be moved unnecessarily until the extent of injuries is known, making gait evaluation impossible. Bowel and bladder functions aren't vital, so the nurse should delay their assessment.

23) B
- Patching one eye at a time relieves diplopia. Closing the eyes and making the room dark aren't the most appropriate options because they deprive the client of sensory input. Artificial tears relieve eye dryness but don't treat double vision.

24) C
- A client with vertigo experiences problems with the inner ear. The inner ear is responsible for maintaining equilibrium. The external ear collects sound; the middle ear conducts sound. The tympanic membrane (eardrum) vibrates in response to sound stimulation.

25) A
- A decreased acetylcholine level has been implicated as a cause of cognitive changes in healthy geriatric clients and in the severity of dementia. Choline acetyltransferase, an enzyme necessary for acetylcholine synthesis, has been found to be deficient in clients with dementia. Norepinephrine is associated with aggression, sleep-wake patterns, and the regulation of physical responses to emotional stimuli, such as the increased heart and respiratory rates caused by panic.

---> Nursing Neurological Exam 21-25

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