Chapter 23: Neurologic System My Nursing Test Banks

Chapter 23: Neurologic System

Jarvis: Physical Examination & Health Assessment, 7th Edition

MULTIPLE CHOICE

1. The two parts of the nervous system are the:

a.

Motor and sensory.

b.

Central and peripheral.

c.

Peripheral and autonomic.

d.

Hypothalamus and cerebral.

ANS: B

The nervous system can be divided into two partscentral and peripheral. The central nervous system includes the brain and spinal cord. The peripheral nervous system includes the 12 pairs of cranial nerves (CNs), the 31 pairs of spinal nerves, and all of their branches.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 633

MSC: Client Needs: General

2. The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husbands personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the __________ lobe.

a.

Frontal

b.

Parietal

c.

Occipital

d.

Temporal

ANS: A

The frontal lobe has areas responsible for personality, behavior, emotions, and intellectual function. The parietal lobe has areas responsible for sensation; the occipital lobe is responsible for visual reception; and the temporal lobe is responsible for hearing, taste, and smell.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 633

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

3. Which statement concerning the areas of the brain is true?

a.

The cerebellum is the center for speech and emotions.

b.

The hypothalamus controls body temperature and regulates sleep.

c.

The basal ganglia are responsible for controlling voluntary movements.

d.

Motor pathways of the spinal cord and brainstem synapse in the thalamus.

ANS: B

The hypothalamus is a vital area with many important functions: body temperature controller, sleep center, anterior and posterior pituitary gland regulator, and coordinator of autonomic nervous system activity and emotional status. The cerebellum controls motor coordination, equilibrium, and balance. The basal ganglia control autonomic movements of the body. The motor pathways of the spinal cord synapse in various areas of the spinal cord, not in the thalamus.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 634

MSC: Client Needs: General

4. The area of the nervous system that is responsible for mediating reflexes is the:

a.

Medulla.

b.

Cerebellum.

c.

Spinal cord.

d.

Cerebral cortex.

ANS: C

The spinal cord is the main highway for ascending and descending fiber tracts that connect the brain to the spinal nerves; it is responsible for mediating reflexes.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 635

MSC: Client Needs: General

5. While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation, which of these areas must be intact?

a.

Corticospinal tract, medulla, and basal ganglia

b.

Pyramidal tract, hypothalamus, and sensory cortex

c.

Lateral spinothalamic tract, thalamus, and sensory cortex

d.

Anterior spinothalamic tract, basal ganglia, and sensory cortex

ANS: C

The spinothalamic tract contains sensory fibers that transmit the sensations of pain, temperature, and crude or light touch. Fibers carrying pain and temperature sensations ascend the lateral spinothalamic tract, whereas the sensations of crude touch form the anterior spinothalamic tract. At the thalamus, the fibers synapse with another sensory neuron, which carries the message to the sensory cortex for full interpretation. The other options are not correct.

DIF: Cognitive Level: Applying (Application) REF: p. 635

MSC: Client Needs: General

6. A patient with a lack of oxygen to his heart will have pain in his chest and possibly in the shoulder, arms, or jaw. The nurse knows that the best explanation why this occurs is which one of these statements?

a.

A problem exists with the sensory cortex and its ability to discriminate the location.

b.

The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing the pain.

c.

The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere.

d.

A lesion has developed in the dorsal root, which is preventing the sensation from being transmitted normally.

ANS: C

The sensory cortex is arranged in a specific pattern, forming a corresponding map of the body. Pain in the right hand is perceived at a specific spot on the map. Some organs, such as the heart, liver, and spleen, are absent from the brain map. Pain originating in these organs is referred because no felt image exists in which to have pain. Pain is felt by proxy, that is, by another body part that does have a felt image. The other responses are not correct explanations.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 636

MSC: Client Needs: Physiologic Integrity: Basic Care and Comfort

7. The ability that humans have to perform very skilled movements such as writing is controlled by the:

a.

Basal ganglia.

b.

Corticospinal tract.

c.

Spinothalamic tract.

d.

Extrapyramidal tract.

ANS: B

Corticospinal fibers mediate voluntary movement, particularly very skilled, discrete, and purposeful movements, such as writing. The corticospinal tract, also known as the pyramidal tract, is a newer, higher motor system that humans have that permits very skilled and purposeful movements. The other responses are not related to skilled movements.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 636

MSC: Client Needs: General

8. A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse?

a.

Thalamus

b.

Brainstem

c.

Cerebellum

d.

Extrapyramidal tract

ANS: C

The cerebellar system coordinates movement, maintains equilibrium, and helps maintain posture. The thalamus is the primary relay station where sensory pathways of the spinal cord, cerebellum, and brainstem form synapses on their way to the cerebral cortex. The brainstem consists of the midbrain, pons, and medulla and has various functions, especially concerning autonomic centers. The extrapyramidal tract maintains muscle tone for gross automatic movements, such as walking.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 637

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

9. Which of these statements about the peripheral nervous system is correct?

a.

The CNs enter the brain through the spinal cord.

b.

Efferent fibers carry sensory input to the central nervous system through the spinal cord.

c.

The peripheral nerves are inside the central nervous system and carry impulses through their motor fibers.

d.

The peripheral nerves carry input to the central nervous system by afferent fibers and away from the central nervous system by efferent fibers.

ANS: D

A nerve is a bundle of fibers outside of the central nervous system. The peripheral nerves carry input to the central nervous system by their sensory afferent fibers and deliver output from the central nervous system by their efferent fibers. The other responses are not related to the peripheral nervous system.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 637

MSC: Client Needs: General

10. A patient has a severed spinal nerve as a result of trauma. Which statement is true in this situation?

a.

Because there are 31 pairs of spinal nerves, no effect results if only one nerve is severed.

b.

The dermatome served by this nerve will no longer experience any sensation.

c.

The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve.

d.

A severed spinal nerve will only affect motor function of the patient because spinal nerves have no sensory component.

ANS: C

A dermatome is a circumscribed skin area that is primarily supplied from one spinal cord segment through a particular spinal nerve. The dermatomes overlap, which is a form of biologic insurance; that is, if one nerve is severed, then most of the sensations can be transmitted by the spinal nerve above and the spinal nerve below the severed nerve.

DIF: Cognitive Level: Applying (Application) REF: p. 639

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

11. A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patients deep tendon reflexes?

a.

Reflexes will be normal.

b.

Reflexes cannot be elicited.

c.

All reflexes will be diminished but present.

d.

Some reflexes will be present, depending on the area of injury.

ANS: A

A reflex is a defense mechanism of the nervous system. It operates below the level of conscious control and permits a quick reaction to potentially painful or damaging situations.

DIF: Cognitive Level: Applying (Application) REF: p. 637

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

12. A mother of a 1-month-old infant asks the nurse why it takes so long for infants to learn to roll over. The nurse knows that the reason for this is:

a.

A demyelinating process must be occurring with her infant.

b.

Myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated.

c.

The cerebral cortex is not fully developed; therefore, control over motor function gradually occurs.

d.

The spinal cord is controlling the movement because the cerebellum is not yet fully developed.

ANS: B

The infants sensory and motor development proceeds along with the gradual acquisition of myelin, which is needed to conduct most impulses. Very little cortical control exists, and the neurons are not yet myelinated. The other responses are not correct.

DIF: Cognitive Level: Applying (Application) REF: p. 640

MSC: Client Needs: Health Promotion and Maintenance

13. During an assessment of an 80-year-old patient, the nurse notices the following: an inability to identify vibrations at her ankle and to identify the position of her big toe, a slower and more deliberate gait, and a slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate:

a.

CN dysfunction.

b.

Lesion in the cerebral cortex.

c.

Normal changes attributable to aging.

d.

Demyelination of nerves attributable to a lesion.

ANS: C

Some aging adults show a slower response to requests, especially for those calling for coordination of movements. The findings listed are normal in the absence of other significant abnormal findings. The other responses are incorrect.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 640

MSC: Client Needs: Health Promotion and Maintenance

14. A 70-year-old woman tells the nurse that every time she gets up in the morning or after shes been sitting, she gets really dizzy and feels like she is going to fall over. The nurses best response would be:

a.

Have you been extremely tired lately?

b.

You probably just need to drink more liquids.

c.

Ill refer you for a complete neurologic examination.

d.

You need to get up slowly when youve been lying down or sitting.

ANS: D

Aging is accompanied by a progressive decrease in cerebral blood flow. In some people, this decrease causes dizziness and a loss of balance with a position change. These individuals need to be taught to get up slowly. The other responses are incorrect.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 640

MSC: Client Needs: Health Promotion and Maintenance

15. During the taking of the health history, a patient tells the nurse that it feels like the room is spinning around me. The nurse would document this finding as:

a.

Vertigo.

b.

Syncope.

c.

Dizziness.

d.

Seizure activity.

ANS: A

True vertigo is rotational spinning caused by a neurologic dysfunction or a problem in the vestibular apparatus or the vestibular nuclei in the brainstem. Syncope is a sudden loss of strength or a temporary loss of consciousness. Dizziness is a lightheaded, swimming sensation. Seizure activity is characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances.

DIF: Cognitive Level: Applying (Application) REF: p. 641

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

16. When taking the health history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information?

a.

Does your muscle tone seem tense or limp?

b.

After the seizure, do you spend a lot of time sleeping?

c.

Do you have any warning sign before your seizure starts?

d.

Do you experience any color change or incontinence during the seizure?

ANS: C

Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or motor. The other questions do not solicit information about an aura.

DIF: Cognitive Level: Applying (Application) REF: p. 641

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

17. While obtaining a health history of a 3-month-old infant from the mother, the nurse asks about the infants ability to suck and grasp the mothers finger. What is the nurse assessing?

a.

Reflexes

b.

Intelligence

c.

CNs

d.

Cerebral cortex function

ANS: A

Questions regarding reflexes include such questions as, What have you noticed about the infants behavior, Are the infants sucking and swallowing seem coordinated, and Does the infant grasp your finger? The other responses are incorrect.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 642

MSC: Client Needs: Health Promotion and Maintenance

18. In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what response should the nurse make?

a.

Does your family know you are drinking every day?

b.

Does the tremor change when you drink alcohol?

c.

Well do some tests to see what is causing the tremor.

d.

You really shouldnt drink so much alcohol; it may be causing your tremor.

ANS: B

Senile tremor is relieved by alcohol, although not a recommended treatment. The nurse should assess whether the person is abusing alcohol in an effort to relieve the tremor.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 643

MSC: Client Needs: Health Promotion and Maintenance

19. A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination?

a.

Glasgow Coma Scale

b.

Neurologic recheck examination

c.

Screening neurologic examination

d.

Complete neurologic examination

ANS: D

The nurse should perform a complete neurologic examination on an individual who has neurologic concerns (e.g., headache, weakness, loss of coordination) or who is showing signs of neurologic dysfunction. The Glasgow Coma Scale is used to define a persons level of consciousness. The neurologic recheck examination is appropriate for those who are demonstrating neurologic deficits. The screening neurologic examination is performed on seemingly well individuals who have no significant subjective findings from the health history.

DIF: Cognitive Level: Applying (Application) REF: p. 644

MSC: Client Needs: Health Promotion and Maintenance

20. During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs?

a.

Motor component of CN IV

b.

Motor component of CN VII

c.

Motor and sensory components of CN XI

d.

Motor component of CN X and sensory component of CN VII

ANS: B

The findings listed reflect a dysfunction of the motor component of the facial nerve (CN VII).

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 646

MSC: Client Needs: Health Promotion and Maintenance

21. The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient:

a.

Demonstrates the ability to hear normal conversation.

b.

Sticks out the tongue midline without tremors or deviation.

c.

Follows an object with his or her eyes without nystagmus or strabismus.

d.

Moves the head and shoulders against resistance with equal strength.

ANS: D

The following normal findings are expected when testing the spinal accessory nerve (CN XI): The patients sternomastoid and trapezius muscles are equal in size; the person can forcibly rotate the head both ways against resistance applied to the side of the chin with equal strength; and the patient can shrug the shoulders against resistance with equal strength on both sides. Checking the patients ability to hear normal conversation checks the function of CN VIII. Having the patient stick out the tongue checks the function of CN XII. Testing the eyes for nystagmus or strabismus is performed to check CNs III, IV, and VI.

DIF: Cognitive Level: Applying (Application) REF: p. 646

MSC: Client Needs: Health Promotion and Maintenance

22. During the neurologic assessment of a healthy 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find?

a.

Firm, rigid resistance to movement

b.

Mild, even resistance to movement

c.

Hypotonic muscles as a result of total relaxation

d.

Slight pain with some directions of movement

ANS: B

Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows a mild resistance to passive stretching. Normally, the nurse will notice a mild, even resistance to movement. The other responses are not correct.

DIF: Cognitive Level: Applying (Application) REF: p. 647

MSC: Client Needs: Health Promotion and Maintenance

23. When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:

a.

Ataxia.

b.

Lack of coordination.

c.

Negative Homans sign.

d.

Positive Romberg sign.

ANS: D

Abnormal findings for the Romberg test include swaying, falling, and a widening base of the feet to avoid falling. A positive Romberg sign is a loss of balance that is increased by the closing of the eyes. Ataxia is an uncoordinated or unsteady gait. Homans sign is used to test the legs for deep-vein thrombosis.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 650

MSC: Client Needs: Health Promotion and Maintenance

24. The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of always dropping things and falling down. While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect?

a.

Vestibular disease

b.

Lesion of CN IX

c.

Dysfunction of the cerebellum

d.

Inability to understand directions

ANS: C

When a person tries to perform rapid, alternating movements, responses that are slow, clumsy, and sloppy are indicative of cerebellar disease. The other responses are incorrect.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 648

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

25. During the taking of the health history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: He cant even remember how to button his shirt. When assessing his sensory system, which action by the nurse is most appropriate?

a.

The nurse would not test the sensory system as part of the examination because the results would not be valid.

b.

The nurse would perform the tests, knowing that mental status does not affect sensory ability.

c.

The nurse would proceed with an explanation of each test, making certain that the wife understands.

d.

Before testing, the nurse would assess the patients mental status and ability to follow directions.

ANS: D

The nurse should ensure the validity of the sensory system testing by making certain that the patient is alert, cooperative, comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading and invalid results.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 644

MSC: Client Needs: Health Promotion and Maintenance

26. The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception, the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one very sharp prick. What would be the most accurate explanation for this?

a.

The patient has hyperesthesia as a result of the aging process.

b.

This response is most likely the result of the summation effect.

c.

The nurse was probably not poking hard enough with the pin in the other areas.

d.

The patient most likely has analgesia in some areas of arm and hyperalgesia in others.

ANS: B

At least 2 seconds should be allowed to elapse between each stimulus to avoid summation. With summation, frequent consecutive stimuli are perceived as one strong stimulus. The other responses are incorrect.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 652

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

27. The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect?

a.

Hyperalgesia

b.

Hyperesthesia

c.

Peripheral neuropathy

d.

Lesion of sensory cortex

ANS: C

Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism). Peripheral neuropathy is worse at the feet and gradually improves as the examiner moves up the leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome. The other responses are incorrect.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 653

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

28. The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding?

a.

Extinction

b.

Astereognosis

c.

Graphesthesia

d.

Tactile discrimination

ANS: B

Stereognosis is the persons ability to recognize objects by feeling their forms, sizes, and weights. Astereognosis is an inability to identify objects correctly, and it occurs in sensory cortex lesions. Tactile discrimination tests fine touch. Extinction tests the persons ability to feel sensations on both sides of the body at the same point.

DIF: Cognitive Level: Applying (Application) REF: p. 654

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

29. The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit a reflex. The nurses next response should be to:

a.

Ask the patient to lock her fingers and pull.

b.

Complete the examination, and then test these reflexes again.

c.

Refer the patient to a specialist for further testing.

d.

Document these reflexes as 0 on a scale of 0 to 4+.

ANS: A

Sometimes the reflex response fails to appear. Documenting the reflexes as absent is inappropriate this soon in the examination. The nurse should try to further encourage relaxation, varying the persons position or increasing the strength of the blow. Reinforcement is another technique to relax the muscles and enhance the response. The person should be asked to perform an isometric exercise in a muscle group somewhat away from the one being tested. For example, to enhance a patellar reflex, the person should be asked to lock the fingers together and pull.

DIF: Cognitive Level: Applying (Application) REF: p. 656

MSC: Client Needs: Health Promotion and Maintenance

30. In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side?

a.

Lack of reflexes

b.

Normal reflexes

c.

Diminished reflexes

d.

Hyperactive reflexes

ANS: D

Hyperreflexia is the exaggerated reflex observed when the monosynaptic reflex arc is released from the influence of higher cortical levels. This response occurs with upper motor neuron lesions (e.g., a cerebrovascular accident). The other responses are incorrect.

DIF: Cognitive Level: Applying (Application) REF: p. 655

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

31. When the nurse is testing the triceps reflex, what is the expected response?

a.

Flexion of the hand

b.

Pronation of the hand

c.

Extension of the forearm

d.

Flexion of the forearm

ANS: C

The normal response of the triceps reflex is extension of the forearm. The normal response of the biceps reflex causes flexion of the forearm. The other responses are incorrect.

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 657

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

32. The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding?

a.

Positive Babinski sign

b.

Plantar reflex abnormal

c.

Plantar reflex present

d.

Plantar reflex 2+ on a scale from 0 to 4+

ANS: C

With the same instrument, the nurse should draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot, similar to an upside-down J. The normal response is plantar flexion of the toes and sometimes of the entire foot. A positive Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and fanning of all toes. The plantar reflex is not graded on a 0 to 4+ scale.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 660

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

33. In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise or stimulation. The mother reports that in the last week he has been sleeping all of the time, and when he is awake all he does is cry. The nurse hears that the infants cries are very high pitched and shrill. What should be the nurses appropriate response to these findings?

a.

Refer the infant for further testing.

b.

Talk with the mother about eating habits.

c.

Do nothing; these are expected findings for an infant this age.

d.

Tell the mother to bring the baby back in 1 week for a recheck.

ANS: A

A high-pitched, shrill cry or cat-sounding screech occurs with central nervous system damage. Lethargy, hyporeactivity, and hyperirritability, as well as the parents report of significant changes in behavior all warrant referral. The other options are not correct responses.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 661

MSC: Client Needs: Health Promotion and Maintenance

34. Which of these tests would the nurse use to check the motor coordination of an 11-month-old infant?

a.

Denver II

b.

Stereognosis

c.

Deep tendon reflexes

d.

Rapid alternating movements

ANS: A

To screen gross and fine motor coordination, the nurse should use the Denver II with its age-specific developmental milestones. Stereognosis tests a persons ability to recognize objects by feeling them and is not appropriate for an 11-month-old infant. Testing the deep tendon reflexes is not appropriate for checking motor coordination. Testing rapid alternating movements is appropriate for testing coordination in adults.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 662

MSC: Client Needs: Health Promotion and Maintenance

35. To assess the head control of a 4-month-old infant, the nurse lifts up the infant in a prone position while supporting his chest. The nurse looks for what normal response? The infant:

a.

Raises the head, and arches the back.

b.

Extends the arms, and drops down the head.

c.

Flexes the knees and elbows with the back straight.

d.

Holds the head at 45 degrees, and keeps the back straight.

ANS: A

At 3 months of age, the infant raises the head and arches the back as if in a swan dive. This response is the Landau reflex, which persists until 1 years of age (see Figure 23-43). The other responses are incorrect.

DIF: Cognitive Level: Applying (Application) REF: p. 663

MSC: Client Needs: Health Promotion and Maintenance

36. While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of the arms and legs; fanning of the fingers, and curling of the index finger and thumb in a C position, followed by the infant bringing in the arms and legs to the body. What does the nurse know about this response?

a.

This response could indicate brachial nerve palsy.

b.

This reaction is an expected startle response at this age.

c.

This reflex should have disappeared between 1 and 4 months of age.

d.

This response is normal as long as the movements are bilaterally symmetric.

ANS: C

The Moro reflex is present at birth and usually disappears at 1 to 4 months. Absence of the Moro reflex in the newborn or its persistence after 5 months of age indicates severe central nervous system injury. The other responses are incorrect.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 666

MSC: Client Needs: Health Promotion and Maintenance

37. To test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate? Ask the child to:

a.

Hop on one foot.

b.

Stand on his head.

c.

Touch his finger to his nose.

d.

Make funny faces at the nurse.

ANS: A

Normally, a child can hop on one foot and can balance on one foot for approximately 5 seconds by 4 years of age and can balance on one foot for 8 to 10 seconds at 5 years of age. Children enjoy performing these tests. Failure to hop after 5 years of age indicates incoordination of gross motor skills. Asking the child to touch his or her finger to the nose checks fine motor coordination; and asking the child to make funny faces tests CN VII. Asking a child to stand on his or her head is not appropriate.

DIF: Cognitive Level: Applying (Application) REF: p. 668

MSC: Client Needs: Health Promotion and Maintenance

38. During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. No associated rigidity is observed with movement. Which of these statements is most accurate?

a.

These findings are normal, resulting from aging.

b.

These findings could be related to hyperthyroidism.

c.

These findings are the result of Parkinson disease.

d.

This patient should be evaluated for a cerebellar lesion.

ANS: A

Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson disease include rigidity, slowness, and a weakness of voluntary movement. The other responses are incorrect.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 669

MSC: Client Needs: Health Promotion and Maintenance

39. While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of a(n):

a.

Great sense of humor.

b.

Uncooperative behavior.

c.

Inability to understand questions.

d.

Decreased level of consciousness.

ANS: D

A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect.

DIF: Cognitive Level: Applying (Application) REF: p. 670

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

40. The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment?

a.

CNs, motor function, and sensory function

b.

Deep tendon reflexes, vital signs, and coordinated movements

c.

Level of consciousness, motor function, pupillary response, and vital signs

d.

Mental status, deep tendon reflexes, sensory function, and pupillary response

ANS: C

Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process. These people must be closely monitored for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure. The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness, motor function, pupillary response, and vital signs.

DIF: Cognitive Level: Applying (Application) REF: p. 670

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

41. During an assessment of a 22-year-old woman who sustained a head injury from an automobile accident 4 hours earlier, the nurse notices the following changes: pupils were equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What do these findings suggest?

a.

Injury to the right eye

b.

Increased intracranial pressure

c.

Test inaccurately performed

d.

Normal response after a head injury

ANS: B

In a person with a brain injury, a sudden, unilateral, dilated, and nonreactive pupil is ominous. CN III runs parallel to the brainstem. When increasing intracranial pressure pushes down the brainstem (uncal herniation), it puts pressure on CN III, causing pupil dilation. The other responses are incorrect.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 671

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

42. A 32-year-old woman tells the nurse that she has noticed very sudden, jerky movements mainly in her hands and arms. She says, They seem to come and go, primarily when I am trying to do something. I havent noticed them when Im sleeping. This description suggests:

a.

Tics.

b.

Athetosis.

c.

Myoclonus.

d.

Chorea.

ANS: D

Chorea is characterized by sudden, rapid, jerky, purposeless movements that involve the limbs, trunk, or face. Chorea occurs at irregular intervals, and the movements are all accentuated by voluntary actions. (See Table 23-5 for the descriptions of athetosis, myoclonus, and tics.)

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 680

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

43. During an assessment of a 62-year-old man, the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements. These findings would be consistent with:

a.

Parkinsonism.

b.

Cerebral palsy.

c.

Cerebellar ataxia.

d.

Muscular dystrophy.

ANS: A

The stooped posture, shuffling walk, short steps, flat facial expression, and pill-rolling finger movements are all found in parkinsonism. (See Table 23-8 for more information and for the descriptions of the other options.)

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 685

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

44. During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion. Which statement concerning these findings is most accurate? This patients response:

a.

Indicates a lesion of the cerebral cortex.

b.

Indicates a completely nonfunctional brainstem.

c.

Is normal and will go away in 24 to 48 hours.

d.

Is a very ominous sign and may indicate brainstem injury.

ANS: D

These findings are all indicative of decerebrate rigidity, which is a very ominous condition and may indicate a brainstem injury.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 688

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

45. A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing?

a.

Scissors gait

b.

Cerebellar ataxia

c.

Parkinsonian gait

d.

Spastic hemiparesis

ANS: D

With spastic hemiparesis, the arm is immobile against the body. Flexion of the shoulder, elbow, wrist, and fingers occurs, and adduction of the shoulder, which does not swing freely, is observed. The leg is stiff and extended and circumducts with each step. Causes of this type of gait include cerebrovascular accident. (See Table 23-6 for more information and for the descriptions of the other abnormal gaits.)

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 683

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

46. In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect?

a.

Hyperreflexia

b.

Fasciculations

c.

Loss of muscle tone and flaccidity

d.

Atrophy and wasting of the muscles

ANS: A

Hyperreflexia, diminished or absent superficial reflexes, and increased muscle tone or spasticity can be expected with upper motor neuron lesions. The other options reflect a lesion of lower motor neurons (see Table 23-7).

DIF: Cognitive Level: Applying (Application) REF: p. 684

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

47. A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on physical assessment of this individual?

a.

Hyporeflexia

b.

Increased muscle tone

c.

Positive Babinski sign

d.

Presence of pathologic reflexes

ANS: A

With a herniated intervertebral disk or lower motor neuron lesion, loss of tone, flaccidity, atrophy, fasciculations, and hyporeflexia or areflexia are demonstrated. No Babinski sign or pathologic reflexes would be observed (see Table 23-7). The other options reflect a lesion of upper motor neurons.

DIF: Cognitive Level: Applying (Application) REF: p. 655

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

48. A patient is unable to perform rapid alternating movements such as rapidly patting her knees. The nurse should document this inability as:

a.

Ataxia.

b.

Astereognosis.

c.

Presence of dysdiadochokinesia.

d.

Loss of kinesthesia.

ANS: C

Slow clumsy movements and the inability to perform rapid alternating movements occur with cerebellar disease. The condition is termed dysdiadochokinesia. Ataxia is an uncoordinated or unsteady gait. Astereognosis is the inability to identify an object by feeling it. Kinesthesia is the persons ability to perceive passive movement of the extremities or the loss of position sense.

DIF: Cognitive Level: Applying (Application) REF: p. 648

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

49. The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)?

a.

Cerebrum

b.

Cerebellum

c.

CNs

d.

Medulla oblongata

ANS: A

The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement. The other structures are not responsible for a persons level of consciousness.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 670

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

50. During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct? Severe nystagmus in both eyes:

a.

Is a normal occurrence.

b.

May indicate disease of the cerebellum or brainstem.

c.

Is a sign that the patient is nervous about the examination.

d.

Indicates a visual problem, and a referral to an ophthalmologist is indicated.

ANS: B

End-point nystagmus at an extreme lateral gaze normally occurs; however, the nurse should carefully assess any other nystagmuses. Severe nystagmus occurs with disease of the vestibular system, cerebellum, or brainstem.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 645

MSC: Client Needs: Health Promotion and Maintenance

51. The nurse knows that testing kinesthesia is a test of a persons:

a.

Fine touch.

b.

Position sense.

c.

Motor coordination.

d.

Perception of vibration.

ANS: B

Kinesthesia, or position sense, is the persons ability to perceive passive movements of the extremities. The other options are incorrect.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 653

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

52. The nurse is reviewing a patients medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma?

a.

6

b.

12

c.

15

d.

24

ANS: A

A fully alert, normal person has a score of 15, whereas a score of 7 or less reflects coma on the Glasgow Coma Scale (see Figure 23-59).

DIF: Cognitive Level: Applying (Application) REF: p. 673

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

53. A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination; he said he fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurses finger, then his own nose, then the nurses finger again (which has been moved to a different location). The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger. The nurse should suspect which of the following?

a.

Cerebral injury

b.

Cerebrovascular accident

c.

Acute alcohol intoxication

d.

Peripheral neuropathy

ANS: C

During the finger-to-finger test, if the person has clumsy movement with overshooting the mark, either a cerebellar disorder or acute alcohol intoxication should be suspected. The persons movements should be smooth and accurate. The other options are not correct.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 648

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

54. The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patients toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as:

a.

Negative Babinski sign, which is normal for adults.

b.

Positive Babinski sign, which is abnormal for adults.

c.

Clonus, which is a hyperactive response.

d.

Achilles reflex, which is an expected response.

ANS: B

Dorsiflexion of the big toe and fanning of all toes is a positive Babinski sign, also called up-going toes. This response occurs with upper motor neuron disease of the corticospinal (or pyramidal) tract and is an abnormal finding for adults.

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 660

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

MULTIPLE RESPONSE

1. A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying Im just getting old! After the nurse completes a thorough neurologic assessment, which findings would be indicative of Alzheimer disease? Select all that apply.

a.

Occasionally forgetting names or appointments

b.

Difficulty performing familiar tasks, such as placing a telephone call

c.

Misplacing items, such as putting dish soap in the refrigerator

d.

Sometimes having trouble finding the right word

e.

Rapid mood swings, from calm to tears, for no apparent reason

f.

Getting lost in ones own neighborhood

ANS: B, C, E, F

Difficulty performing familiar tasks, misplacing items, rapid mood swings, and getting lost in ones own neighborhood can be warning signs of Alzheimer disease. Occasionally forgetting names or appointments, and sometimes having trouble finding the right word are part of normal aging. (For other examples of Alzheimer disease, see Table 23-2.)

DIF: Cognitive Level: Applying (Application) REF: p. 677

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

SHORT ANSWER

1. During the assessment of deep tendon reflexes, the nurse finds that a patients responses are bilaterally normal. What number is used to indicate normal deep tendon reflexes when the documenting this finding? ____+

ANS:

2

Responses to assessment of deep tendon reflexes are graded on a 4-point scale. A rating of 2+ indicates normal or average response. A rating of 0 indicates no response, and a rating of 4+ indicates very brisk, hyperactive response with clonus, which is indicative of disease.

DIF: Cognitive Level: Applying (Application) REF: p. 655

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

Leave a Reply