The nurse is caring for a patient with a new traumatic brain injury and completes a neurologic assessment. The magnetic resonance imaging identifies an intracranial epidural hematoma. The nurse would immediately notify the provider of which assessment finding?

Eyes are deviated to the right.

Amnesia to the cause of the trauma.

Complaint of mild headache.

Pupils constrict from 5 mm to 2 mm with direct light stimulus.

Answer and Explanation

The Correct Answer is A

Choice A reason: Eyes are deviated to the right is an assessment finding that indicates increased intracranial pressure and possible herniation of the brain. It is a sign of cranial nerve III palsy, which affects the movement of the eye and the size of the pupil. It is a medical emergency that requires immediate intervention.

Choice B reason: Amnesia to the cause of the trauma is an assessment finding that indicates memory loss and possible concussion. It is a sign of damage to the temporal lobe, which is involved in memory formation and retrieval. It is not a medical emergency, but it requires further evaluation and monitoring.

Choice C reason: Complaint of mild headache is an assessment finding that indicates pain and discomfort. It is a common symptom of traumatic brain injury, but it is not specific or severe. It can be managed with analgesics and rest.

Choice D reason: Pupils constrict from 5 mm to 2 mm with direct light stimulus is an assessment finding that indicates normal pupillary response. It is a sign of intact cranial nerve II and III function, which control the vision and the pupil size. It is not a cause for concern or notification.

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Correct Answer is A

Explanation

Choice A reason: The hypoglossal nerve is responsible for the movement of the tongue. It innervates the muscles of the tongue and allows for speech, swallowing, and chewing.

Choice B reason: The trigeminal nerve is responsible for the sensation and motor function of the face. It innervates the muscles of mastication, the skin of the face, and the mucous membranes of the mouth and nose.

Choice C reason: The facial nerve is responsible for the expression and taste of the face. It innervates the muscles of facial expression, the lacrimal and salivary glands, and the anterior two-thirds of the tongue.

Choice D reason: The vestibulocochlear nerve is responsible for the hearing and balance of the ear. It innervates the cochlea and the vestibular apparatus of the inner ear.

A. arm and leg weakness, paresthesia, blurred vision, and facial frown. B. uncontrollable rapid jerky movements in arms, trunk and facial muscles. C. stumbling, backward tilt of the head, quick fluttering hand movements, and quick uncontrolled gait. D. hand tremors, bradykinesia, skeletal muscle rigidity, and postural instability.

Correct Answer is D

Explanation

Choice A reason: This is incorrect. Arm and leg weakness, paresthesia, blurred vision, and facial frown are not specific to Parkinson disease, but may be seen in other neurological disorders, such as multiple sclerosis or stroke.

Choice B reason: This is incorrect. Uncontrollable rapid jerky movements in arms, trunk and facial muscles are characteristic of Huntington disease, not Parkinson disease. Huntington disease is a genetic disorder that causes progressive degeneration of the nerve cells in the brain.

Choice C reason: This is incorrect. Stumbling, backward tilt of the head, quick fluttering hand movements, and quick uncontrolled gait are signs of cerebellar ataxia, not Parkinson disease. Cerebellar ataxia is a disorder that affects the coordination and balance of the movements, caused by damage to the cerebellum.

Choice D reason: This is correct. Hand tremors, bradykinesia, skeletal muscle rigidity, and postural instability are the cardinal signs and symptoms of Parkinson disease. Parkinson disease is a chronic and progressive disorder that affects the dopamine-producing neurons in the brain, resulting in movement problems.

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The nurse is caring for a patient with a new traumatic brain injury and completes a neurologic assessment. The magnetic resonance imaging identifies an intracranial epidural hematoma. The nurse would immediately notify the provider of which assessment finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is evaluating the cranial nerves of a person with Parkinson disease who has difficulty swallowing foods. The nurse asks the patient to stick out their tongue and move it rapidly from side to side. The nurse is assessing which cranial nerve?

Correct Answer is A

Explanation

The cardinal signs and symptoms of Parkinson disease are?

Correct Answer is D

Explanation

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