Chapter 22: The Neurologic System My Nursing Test Banks

Chapter 22: The Neurologic System

MULTIPLE CHOICE

1. The nurse is caring for the patient who has had an injury to the hypothalamus. Which intervention will the nurse be most concerned with implementing?

a.

Maintaining environmental temperature control

b.

Monitoring for signs of hemorrhage

c.

Protecting the eyes from bright lights

d.

Providing care designed to preserve skin integrity

ANS: A

The hypothalamus regulates body temperature; therefore, it is important to maintain adequate temperature control of the environment since the bodys ability to regulate the temperature will be affected by injury to the organ. Bleeding, photophobia, and skin integrity are not issues associated with the hypothalamus.

DIF: Cognitive Level: Application REF: 473 | Table 22-1

OBJ: 6 (theory) TOP: Hypothalamus

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

2. The nurse differentiates the sympathetic from the parasympathetic nervous systems in that the sympathetic system:

a.

provides energy for fight or flight in stressful situations.

b.

slows the heart rate after a stressful situation.

c.

supports deep sleep after large expenditures of energy.

d.

relaxes blood vessels to counteract hypertension.

ANS: A

The sympathetic nervous system gears up the body for fight or flight situations with epinephrine that will raise the blood pressure, reduce bowel motility, and energize the whole body to defend itself in a stressful situation.

DIF: Cognitive Level: Application REF: 476 | Table 22-3

OBJ: 2 (theory) TOP: Sympathetic Nervous System

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. The nurse assessing an 80-year-old attributes the slowed knee jerk reflex with which age-related change?

a.

Diminished brain cells

b.

Degeneration of myelin sheath

c.

Weakened muscles

d.

Irritation of nerve roots

ANS: B

Loss of nerve fibers in the autonomic nervous system will cause diminished reflexes in the older adult.

DIF: Cognitive Level: Application REF: 478 OBJ: 2 (theory)

TOP: PNS: Diminished Reflexes KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4. A student nurse questions the nurse about the difference between a quadriplegic and a tetraplegic patient. The nurse correctly reports that a tetraplegic patient:

a.

has fewer fine motor movements.

b.

can experience pain in paralyzed parts.

c.

is more easily rehabilitated.

d.

means the same as a quadriplegic.

ANS: D

Tetraplegia is the newer term for the old term quadriplegia.

DIF: Cognitive Level: Knowledge REF: 492 OBJ: 1 (theory)

TOP: Tetraplegia vs. Quadriplegia KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. The nurse requesting the patient to stick out the tongue and move it rapidly from side to side is assessing the __________ nerve.

a.

hypoglossal

b.

glossopharyngeal

c.

vagal

d.

abducens

ANS: A

The test described is the test for the effectiveness of the hypoglossal nerve (CN XII), which is a cranial motor nerve responsible for tongue movement and articulation of speech.

DIF: Cognitive Level: Comprehension REF: 475 | Table 22-2

OBJ: 5 (theory) TOP: Cranial Nerve Assessment

KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

6. The nurse may record a positive Rombergs test if during the test, the patient:

a.

cannot keep his eyes closed.

b.

cannot touch his nose with eyes closed.

c.

complains of dizziness.

d.

sways from side to side.

ANS: D

The patient is asked to stand with his feet together and to close his eyes. Swaying from side to side during the Rombergs test is a positive sign for impaired balance.

DIF: Cognitive Level: Application REF: 479 OBJ: 5 (theory)

TOP: Rombergs Test KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

7. The nurse explains that a reflex is a simple automatic response requiring only:

a.

one efferent and one afferent impulse and a synapse.

b.

two efferent impulse and one synapse.

c.

two synapses with efferent and afferent impulses.

d.

two afferent impulses and one synapse.

ANS: A

The reflex only requires an efferent and an afferent impulse and one synapse, a very simple response.

DIF: Cognitive Level: Knowledge REF: 479-480 OBJ: 5 (theory)

TOP: Reflex: Definition KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. The nurse interprets the physicians finding of a grade of 2/5 on the Achilles tendon to mean what has occurred?

a.

Hyperreflexive response for the fifth and sixth cervical nerves

b.

Exaggerated response for the seventh and eighth cervical nerves

c.

Normal response for the first and second sacral nerves

d.

Weak response for the second through the fourth lumbar nerves

ANS: C

A score of 2/5 is a normal grade. The Achilles tendon reflex evaluates the first and second sacral nerves.

DIF: Cognitive Level: Comprehension REF: 480 OBJ: 5 (theory)

TOP: Reflexes: Grading KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

9. The reflex that indicates an abnormality in the motor control pathways from the cerebral cortex is the __________ reflex.

a.

Babinski

b.

biceps

c.

brachioradialis

d.

knee jerk

ANS: A

A positive Babinski reflex indicates an abnormality in the motor pathways from the cerebral cortex.

DIF: Cognitive Level: Knowledge REF: 480 | 485 | Figure 22-7

OBJ: 1 (theory) TOP: Babinski Reflex

KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

10. The vital sign assessment of a person with a head injury was temperature (T), 97 F; pulse (P), 86; respiration (R), 18; and blood pressure (BP), 140/86 at 1:00. Which vital sign assessment made 30 minutes later is indicative of increasing intracranial pressure (ICP)?

a.

T, 98 F; P, 78; R, 14; BP, 150/82

b.

T, 97 F; P, 90; R, 20; BP, 148/94

c.

T, 98 F; P, 82; R, 18; BP, 140/74

d.

T, 99 F; P, 92; R, 16; BP, 136/82

ANS: A

An increasing temperature, decreasing pulse and respirations, and a widening pulse pressure are indicative of increasing ICP.

DIF: Cognitive Level: Analysis REF: 485 OBJ: 6 (theory)

TOP: Increasing ICP KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

11. The nurse notes that the Glasgow Coma Scale rating made on the patient 4 hours ago indicated a fully alert patient with a score of _____ points.

a.

25

b.

20

c.

15

d.

10

ANS: C

The Glasgow Coma Scale is used to evaluate a patients neurologic functioning and level of consciousness. Scores range from 3 to 15 points. The higher the score, the higher the level of consciousness. A score of 15 points on the Glasgow Coma Scale indicates a fully alert patient.

DIF: Cognitive Level: Application REF: 486 | Table 22-7

OBJ: 3 (clinical) TOP: Glasgow Coma Scale

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. The assessment of a patients ability to think can be evaluated by asking the patient:

a.

to add three numbers together in his head.

b.

to identify the name of the present month.

c.

what he would do in the event of a fire.

d.

what the last major holiday was.

ANS: A

Thinking can be evaluated by asking the patient to perform simple arithmetic functions in his head.

DIF: Cognitive Level: Application REF: 486 OBJ: 5 (theory)

TOP: Assessment of Thinking KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

13. The nurse is performing a neurologic assessment on a newly admitted head injury patient. Which sign does the nurse recognize as that most indicative of a brainstem injury?

a.

Nystagmus

b.

Decerebrate posturing

c.

Seizure activity

d.

Glasgow Coma Scale score of 3

ANS: B

The appearance of decerebrate as well as decorticate posturing is an indicator of brainstem injury. Nystagmus, seizures, and a Glasgow score of 3 are not necessarily signs of brainstem injury.

DIF: Cognitive Level: Application REF: 487 | Figure 22-10

OBJ: 6 (theory) TOP: Brainstem Injury: Decerebrate Posturing

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

14. The crossed arms of the examiner when assessing muscle strength in a neurologic assessment is done in order to:

a.

align the examiners hands with the patients hands.

b.

create greater distance between the examiner and the patient.

c.

allow a comfortable stance for the examiner.

d.

equalize sensitivity of the examiners hands.

ANS: A

By crossing the arms, the examiners hands and the patients hands are aligned. Whatever the examiner feels in her right hand would be happening in the patients right hand as well.

DIF: Cognitive Level: Comprehension REF: 487 OBJ: 2 (clinical)

TOP: Neuro Check KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

15. When feeding a patient with dysphagia with a left-sided hemiplegia, how should the nurse position the patient?

a.

Side-lying on the right side

b.

Semi-Fowlers

c.

High Fowlers

d.

Upright at a table in a wheelchair

ANS: C

High Fowlers is the most comfortable and safe position. Sitting upright at a table may prove stressful because of weakness and impaired balance.

DIF: Cognitive Level: Application REF: 493 OBJ: 6 (theory)

TOP: Dysphagia KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

16. Bladder training begins with toileting the patient every:

a.

hour.

b.

2 hours.

c.

3 hours.

d.

4 hours.

ANS: B

Bladder training begins with toileting the patient every 2 hours.

DIF: Cognitive Level: Comprehension REF: 493-494 OBJ: 6 (theory)

TOP: Bladder Training KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance

17. A patient is admitted to the hospital to rule out the possibility of bacterial meningitis. Which test will be most helpful in diagnosing this condition?

a.

Magnetoencephalography (MEG)

b.

Myelography

c.

Cerebral angiography

d.

Lumbar puncture for cerebrospinal fluid (CSF) analysis and culture

ANS: D

A lumbar puncture is performed to remove a sample of CSF to detect abnormalities that are indicative of specific neurologic problems and determine which organism is responsible for an infection such as bacterial meningitis.

DIF: Cognitive Level: Application REF: 481 | Table 22-6

OBJ: 4 (theory) TOP: Diagnostic Testing: Lumbar Puncture

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE

18. The patient scheduled for a PET (positron emission tomography) scan of the brain asks if there is any special preparation for the test. The nurse correctly responds with which statements? (Select all that apply.)

a.

There is no special preparation involved with this test since it is noninvasive.

b.

You should avoid any tranquilizers or sedatives the night before and the day of the test.

c.

You will need to sign a consent form for this test to be performed.

d.

You will have an IV inserted for the exam.

e.

Im not really sure. The technicians performing the test will let you know.

ANS: B, C, D

During a PET scan, radioactive material is given through an IV and provides differing color in areas of cellular activity. A consent form is required because this is an invasive test, and tranquilizers and sedatives should be avoided because this PET scan is of brain activity. Telling the patient that the nurse is unsure does not instill confidence or meet the need of the patient.

DIF: Cognitive Level: Application REF: 483 | Table 22-6

OBJ: 5 (theory) TOP: Diagnostic Tests: PET

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

19. The loss of neurons in the autonomic nervous system (ANS) of the older adult will cause the older adult to take longer to: (Select all that apply.)

a.

recuperate from an illness.

b.

apply brakes to stop a car.

c.

form words into sentences.

d.

climb stairs.

e.

learn new material.

ANS: A, B

Recuperation and response times are lengthened with the loss of neurons from the ANS. The other options have to do with loss of strength and mentation.

DIF: Cognitive Level: Application REF: 478 OBJ: 6 (theory)

TOP: ANS: Age-Related Changes KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. The nurse can be proactive in reducing neurologic injuries by: (Select all that apply.)

a.

insisting everyone buckle up before starting the car.

b.

encouraging children to wear bike helmets.

c.

reminding swimmers to test water depth before diving.

d.

encouraging use of hard hats at industrial sites.

e.

discouraging recreational drug use that could bring on a stroke.

ANS: A, B, C, D, E

All options would be supportive of the reduction of CNS injury.

DIF: Cognitive Level: Knowledge REF: 479 | Health Promotion

OBJ: 3 (theory) TOP: Central Nervous System (CNS) Disorders: Prevention

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

21. The FOUR (Full Outline of UnResponsiveness) tool is based on the assessment of the status of the: (Select all that apply.)

a.

eye response.

b.

motor response.

c.

brainstem response.

d.

respiratory function.

e.

reflex response.

ANS: A, B, C, D

Reflex response is not part of the assessment tool.

DIF: Cognitive Level: Comprehension REF: 486 OBJ: 1 (theory)

TOP: FOUR Assessment Tool KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

22. The nurse performs a reflex test on a newly admitted adult patient. The nurse runs a tongue blade along the sole of the foot and the patient responds with the great toe bending backward (upward) and the smaller toes fanning outward. The nurse suspects the patient may be suffering from what? (Select all that apply.)

a.

Injury to the CNS causing an abnormality in the motor control pathways leading from the cerebral cortex

b.

A myocardial infarction that has caused hypoxemia

c.

The influence of chemical substances

d.

Damage to the peripheral nervous system (PNS)

e.

Trauma to the hypothalamus

ANS: A, C

This response in the adult indicates a positive Babinski reflex, indicative of an abnormality in the motor control pathways leading from the cerebral cortex, or from the influence of chemical substances. Hypoxemia, damage to the PNS, and trauma to the hypothalamus would not cause a positive Babinski reflex.

DIF: Cognitive Level: Analysis REF: 480 | 485 | Figure 22-7

OBJ: 6 (theory) TOP: Assessment: Babinski Reflex

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

COMPLETION

23. The component of the peripheral nervous system (PNS) that carries the impulse to the central nervous system (CNS) is the ____________ impulse.

ANS:

afferent

The afferent impulse carries the impulse to the CNS from the PNS.

DIF: Cognitive Level: Knowledge REF: 474 OBJ: 1 (theory)

TOP: PNS: Afferent Impulse KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance

24. There are _______ cranial nerves that control the sensory and motor activities of the body.

ANS:

12

twelve

There are 12 cranial nerves that control the sensory and motor activities of the body.

DIF: Cognitive Level: Knowledge REF: 475 | Table 22-2

OBJ: 5 (theory) TOP: Cranial Nerves KEY: Nursing Process Step: NA

MSC: NCLEX: NA

25. When documenting pupillary response that is normal, the acceptable abbreviation is _______.

ANS:

PERRLA

perrla

PERRLA (Pupils Equally Round and Reactive to Light with Accommodation) is an acceptable and recognizable abbreviation of an assessment of pupillary response.

DIF: Cognitive Level: Comprehension REF: 488 OBJ: 5 (theory)

TOP: Pupillary Response: PERRLA KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

26. A neurologically damaged patient who cannot interpret communication directed to him is said to have ____________ aphasia.

ANS:

receptive

The person who cannot interpret communication is said to have receptive aphasia.

DIF: Cognitive Level: Comprehension REF: 495 OBJ: 6 (clinical)

TOP: Receptive Dysphasia KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

27. During a physical assessment of the neurologic system, the nurse checks the patients __________, which is built into the nervous system and does not need the intervention of conscious thought to take place.

ANS: reflex

DIF: Cognitive Level: Comprehension REF: 479-480 OBJ: 5 (theory)

TOP: Assessment: Reflex KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

MATCHING

The degree of consciousness in an otherwise unresponsive patient can be assessed by the use of progressive painful stimuli. Arrange the painful stimuli in the appropriate sequence of their application.

a.

Press on the orbital notch.

b.

Press the mandibular angle.

c.

Shake gently.

d.

Rub sternum.

e.

Pinch trapezius.

28. Step 1

29. Step 2

30. Step 3

31. Step 4

32. Step 5

28. ANS: C DIF: Cognitive Level: Application REF: 487

OBJ: 5 (theory) TOP: Assessment: Painful Stimuli

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

29. ANS: A DIF: Cognitive Level: Application REF: 487

OBJ: 5 (theory) TOP: Assessment: Painful Stimuli

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

30. ANS: E DIF: Cognitive Level: Application REF: 487

OBJ: 5 (theory) TOP: Assessment: Painful Stimuli

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

31. ANS: B DIF: Cognitive Level: Application REF: 487

OBJ: 5 (theory) TOP: Assessment: Painful Stimuli

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

32. ANS: D DIF: Cognitive Level: Application REF: 487

OBJ: 5 (theory) TOP: Assessment: Painful Stimuli

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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