An acute care nurse is caring for an adult client who is undergoing evaluation for a possible brain tumor. While performing a neurological examination, which of following findings is the earliest indicator of the client's cerebral status?
Pupil response
Deep tendon reflexes
Muscle strength
Level of consciousness
The Correct Answer is D
A. Pupil response:
Pupil response refers to the reaction of the pupils to light stimulus. The pupils should normally constrict when exposed to bright light and dilate in dim light. Changes in pupil size or reactivity can indicate alterations in neurological function. For example, unequal or non-reactive pupils (anisocoria or fixed pupils) can be indicative of dysfunction in the cranial nerves or brainstem. However, while pupil response is an important aspect of neurological assessment, it may not always be the earliest indicator of cerebral status changes.
B. Deep tendon reflexes:
Deep tendon reflexes are involuntary muscle contractions in response to stretching of a muscle tendon. These reflexes are assessed by tapping the tendon with a reflex hammer, eliciting a rapid and brief muscle contraction. Changes in deep tendon reflexes can provide information about the integrity of the peripheral nervous system and spinal cord. However, alterations in deep tendon reflexes may occur secondary to changes in cerebral function and are typically assessed along with other neurological signs.
C. Muscle strength:
Muscle strength refers to the force generated by muscles during voluntary movement. It is typically assessed by asking the client to perform specific movements against resistance or by testing the strength of individual muscle groups using standardized scales (e.g., Medical Research Council scale). Changes in muscle strength can occur due to neurological or musculoskeletal conditions. While weakness or paralysis can result from lesions affecting the upper motor neurons (e.g., strokes or spinal cord injuries), alterations in muscle strength may not always be the earliest indicator of cerebral status changes.
D. Level of consciousness:
The level of consciousness refers to the degree of awareness and alertness exhibited by the client. It is assessed by evaluating the client's responsiveness, orientation, and ability to follow commands. Changes in the level of consciousness, such as confusion, lethargy, stupor, or coma, can indicate alterations in cerebral function and are often the earliest indicators of neurological dysfunction. Assessing the level of consciousness is a critical component of neurological examination and helps guide further assessment and management of clients with suspected brain tumors or other neurological conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E","F"]
Explanation
A. Muscle tremors:
Muscle tremors, particularly resting tremors, are a hallmark feature of Parkinson's disease. These tremors typically occur in the hands, fingers, arms, legs, jaw, or head and may worsen with stress or inactivity.
B. Slow body movement (bradykinesia):
Bradykinesia refers to slowness of movement and is another key symptom of Parkinson's disease. Patients may have difficulty initiating movement, experience a decrease in spontaneous movement (hypokinesia), and demonstrate reduced range of motion.
C. Rigidity:
Rigidity, or stiffness of the muscles, is a common symptom of Parkinson's disease. It often affects the limbs and trunk and can contribute to difficulty with movement and posture.
D. Pill rolling:
Pill rolling refers to a specific type of tremor characterized by rhythmic, rolling movements of the thumb and fingers, resembling the action of rolling a pill between the fingers and thumb. This tremor is commonly seen in Parkinson's disease.
E. Lack of facial expression:
Parkinson's disease can lead to a reduced range of facial expressions, also known as hypomimia or "masked facies." Patients may have a fixed, expressionless facial appearance and reduced blinking.
F. Drooling:
Drooling, or excessive salivation, can occur in Parkinson's disease due to impaired swallowing function (dysphagia) and reduced control over oral and facial muscles.
Correct Answer is A
Explanation
A. Nystagmus:
Nystagmus is an involuntary, rhythmic movement of the eyes, which can be rapid and jerky. It is a common neurological manifestation of phenytoin toxicity. Patients experiencing phenytoin toxicity may exhibit horizontal or vertical nystagmus, which can be detected upon physical examination.
B. Strabismus:
Strabismus, also known as crossed eyes or squint, refers to a misalignment of the eyes. While strabismus can have various causes, it is not typically associated with phenytoin toxicity. Therefore, it is less likely to indicate phenytoin toxicity compared to nystagmus.
C. Blurry vision:
Blurry vision, or visual disturbances, can occur in patients experiencing phenytoin toxicity. However, it is a non-specific symptom and can be observed in various other conditions as well. Patients with phenytoin toxicity may experience blurry vision, double vision (diplopia), or other visual disturbances due to the effects of the medication on the central nervous system.
D. Amblyopia:
Amblyopia, also known as lazy eye, is a condition characterized by reduced vision in one or both eyes. It is typically associated with visual development during childhood and is not directly related to phenytoin toxicity. Therefore, it is less likely to indicate phenytoin toxicity compared to nystagmus or other neurological manifestations.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today