Chapter 24 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 24

Question 1

Type: MCMA

The student nurse is reviewing the cranial nerves. The student recognizes some of the nerves are exclusively sensory nerves. Which of the following cranial nerves belong to this group?

Standard Text: Select all that apply.

1. Olfactory nerve (cranial nerve I)

2. Optic nerve (cranial nerve II)

3. Trochlear nerve (cranial nerve IV)

4. Trigeminal nerve (cranial nerve V)

5. Facial nerve (cranial nerve VII)

Correct Answer: 1,2

Rationale 1: Olfactory nerve (cranial cerve I). The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. The olfactory nerve is a sensory nerve and is responsible for the sense of smell. The optic nerve is a sensory nerve responsible for vision.

Rationale 2: Optic nerve (cranial nerve II). The cranial nerves may be classified by function. The nerves may be sensory, motor or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. The olfactory nerve is a sensory nerve and is responsible for the sense of smell. The optic nerve is a sensory nerve responsible for vision.

Rationale 3: Trochlear nerve (cranial nerve IV). The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. The trochlear nerve is a motor nerve responsible for eye movement.

Rationale 4: Trigeminal nerve (cranial nerve V). The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. The trigeminal nerve is a mixed nerve is responsible for sensory impulses from the lower eyelid, nasal cavity and palate. Motor actions of the trigeminal nerve involve teeth clenching and movement of the mandible.

Rationale 5: Facial nerve (cranial nerve VI). The cranial nerves may be classified by function. The nerves may be sensory, motor or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. The facial nerve is a mixed nerve responsible for taste, facial movements, and the production of tears and salivary stimulation.

Global Rationale: The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. The olfactory nerve is a sensory nerve and is responsible for the sense of smell. The optic nerve is a sensory nerve responsible for vision. The trochlear nerve is a motor nerve responsible for eye movement. The trigeminal nerve is a mixed nerve is responsible for sensory impulses from the lower eyelid, nasal cavity, and palate. Motor actions of the trigeminal nerve involve teeth clenching and movement of the mandible. The facial nerve is a mixed nerve responsible for taste, facial movements, and the production of tears and salivary stimulation.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system.

Question 2

Type: HOTSPOT

The nurse is caring for a client having problems with emotional appropriateness as a result of a brain injury. Mark the area that has most likely been damaged.

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Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The frontal lobe of the cerebrum is responsible for the control of emotions.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system.

Question 3

Type: HOTSPOT

The nurse is caring for a client with a traumatic brain injury. The client has begun to experience bradycardia. What area of the brain is likely responsible for the changes in heart rate?

Screen Shot 2015-09-24 at 12.47.32 PM

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The brain stem is responsible for control of the vital signs.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system.

Question 4

Type: MCSA

The nurse is assessing a client to determine tremors associated with Parkinsons disease. The nurse would correctly observe for which of the following movements?

1. Fasciculations

2. Chorea

3. Rhythmic shaking

4. Athetoid movements

Correct Answer: 3

Rationale 1: Fasciculations are muscle twitches.

Rationale 2: Chores refer to controllable jerking movements as are associated with Huntingtons disease.

Rationale 3: Rhythmic shaking of the hands is a manifestations associated with Parkinsons disease.

Rationale 4: Athetoid moements are repetitive and slow and are seen with cerebral palsy.

Global Rationale: The tremors noted with Parkinsons disease produce rhythmic shaking of the hands. Fasciculations are muscle twitches; chorea is the uncontrollable jerking associated with Huntingtons disease; athetoid movements are repetitive and slow and are seen with cerebral palsy.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system.

Question 5

Type: MCSA

The nurse is performing a neurological assessment on a client experiencing anosmia. The nurse would suspect cranial nerve involvement in which of the following?

1. Trochlear (cranial nerve IV)

2. Trigeminal (cranial nerve V)

3. Olfactory (cranial nerve I)

4. Oculomotor (cranial nerve III)

Correct Answer: 3

Rationale 1: The trochlear nerve (cranial nerve IV) is related to vision. Dysfunction of the trochlear nerve nerve may include diplopia or strabismus.

Rationale 2: The trigeminal nerve (cranial nerve V) is responsible for sensory impulses from scalp, upper eyelid, nose, cornea, and lacrimal gland. Dysfunction of the trigeminal nerve may be associated with a loss of facial sensation.

Rationale 3: Anosmia is the absence of the sense of smell and can be indicative of problems with the olfactory nerve (cranial nerve I).

Rationale 4: The oculomotor nerve (cranial nerve III) is associated with vision.

Global Rationale: Anosmia is the absence of the sense of smell and can be indicative of problems with the olfactory nerve (cranial nerve I). The trochlear nerve (cranial nerve IV) is responsible for eye muscle movements. Dysfunction of the trochlear nerve nerve may include diplopia or strabismus. The trigeminal nerve (cranial nerve V) has three branches. The ophthalmic branch is responsible for sensory impulses from scalp, upper eyelid, nose, cornea, and lacrimal gland. The maxillary branch is responsible for sensory impulses from lower eyelid, nasal cavity, upper teeth, upper lip, and palate. The mandibular branch controls sensory impulses from the tongue, lower teeth, skin of chin, and lower lip. Motor action function includes teeth clenching, movements. Dysfunction of the trigeminal nerve may be associated with a loss of facial sensation, sensation deficits in the tongue, lower teeth, skin of the chin and lower lip, and an inability to clench the teeth. The oculomotor nerve (cranial nerve III) is associated with papillary reflexes and extrinsic muscle movements of the eyes.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system.

Question 6

Type: MCSA

The nurse is assessing the patellar reflex on a client and obtains no reflexive activity. The client is alert and oriented. The nurse should do which of the following in this situation?

1. Document the findings as normal.

2. Notify the healthcare provider immediately.

3. Look at the medication records for central nervous system depressants.

4. Retest the reflex after having the client use distraction during the exam.

Correct Answer: 4

Rationale 1: Reflexes are stimulus-response activities of the body. They are fast, predictable, unlearned, innate, and involuntary reactions to stimuli. The individual is aware of the results of the reflex activity and not the activity itself. The reflex activity may be simple and take place at the level of the spinal cord, with interpretation at the cerebral level. Reflex activity is recorded using a 4-point scale. Normal reflexes are listed as a 2+. The absence of the patellar reflex is not normal. Before concluding that a reflex is absent or diminished the test should be repeated. The client should be encouraged to relax. It may be necessary to distract the client to achieve relaxation of the muscle before striking the tendon. Reflexes are stimulus-response activities of the body. They are fast, predictable, unlearned, innate, and involuntary reactions to stimuli. The individual is aware of the results of the reflex activity and not the activity itself. The reflex activity may be simple and take place at the level of the spinal cord, with interpretation at the cerebral level. Reflex activity is recorded using a 4-point scale. Normal reflexes are listed as a 2+. The absence of the patellar reflex is not normal. Before concluding that a reflex is absent or diminished the test should be repeated.

Rationale 2: There is no immediate need to notify the healthcare provider.

Rationale 3: Reflexes are stimulus-response activities of the body. They are fast, predictable, unlearned, innate, and involuntary reactions to stimuli. The individual is aware of the results of the reflex activity and not the activity itself. The reflex activity may be simple and take place at the level of the spinal cord, with interpretation at the cerebral level. Reflex activity is recorded using a 4-point scale. Normal reflexes are listed as a 2+. The absence of the patellar reflex is not normal. Before concluding that a reflex is absent or diminished the test should be repeated. Medications should eventually be reviewed to determine any impact on the nervous system but this action does not precede attempting to reassess the reflexes.

Rationale 4: Reflexes are stimulus-response activities of the body. They are fast, predictable, unlearned, innate, and involuntary reactions to stimuli. The individual is aware of the results of the reflex activity and not the activity itself. The reflex activity may be simple and take place at the level of the spinal cord, with interpretation at the cerebral level. Reflex activity is recorded using a 4-point scale. Normal reflexes are listed as a 2+. The absence of the patellar reflex is not normal. Before concluding that a reflex is absent or diminished the test should be repeated. The client should be encouraged to relax.

Global Rationale: Reflexes are stimulus-response activities of the body. They are fast, predictable, unlearned, innate, and involuntary reactions to stimuli. The individual is aware of the results of the reflex activity and not the activity itself. The reflex activity may be simple and take place at the level of the spinal cord, with interpretation at the cerebral level. Reflex activity is recorded using a 4-point scale. Normal reflexes are listed as a 2+. The absence of the patellar reflex is not normal. Before concluding that a reflex is absent or diminished the test should be repeated. The client should be encouraged to relax. It may be necessary to distract the client to achieve relaxation of the muscle before striking the tendon. Documentation of the reflexes as normal is not appropriate, as a score of 0 is not normal. There is no immediate need to notify the healthcare provider. Medications should eventually be reviewed to determine any impact on the nervous system but this action does not precede attempting to reassess the reflexes.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.1: Describe the anatomy and physiology of the nervous system.

Question 7

Type: MCSA

The nurse is interviewing a client with suspected Lyme disease. Which of the following questions would be a priority in this situation?

1. When was your last seizure?

2. Have you been hiking or camping lately?

3. What has your temperature been running?

4. Do you have an appetite?

Correct Answer: 2

Rationale 1: Lyme disease is an infection caused by a spirochete transmitted by a bite from an infected tick that lives on deer. This tick exposure may have come from hiking or camping. Lyme disease if not treated may result in neurological disorders. There is not, however, any indication that the client has long-term Lyme disease or neurological changes.

Rationale 2: Lyme disease is an infection caused by a spirochete transmitted by a bite from an infected tick that lives on deer. This tick exposure may have come from hiking or camping.

Rationale 3: Lyme disease is an infection caused by a spirochete transmitted by a bite from an infected tick that lives on deer. This tick exposure may have come from hiking or camping. During the initial period after becoming infected the client may experience flu-like illnesses but there is no indication that this is the primary concern for the client.

Rationale 4: Lyme disease is an infection caused by a spirochete transmitted by a bite from an infected tick that lives on deer. This tick exposure may have come from hiking or camping. An infectious process may result in changes in the clients appetite or dietary but this is not the priority area of concern for investigation.

Global Rationale: Lyme disease is an infection caused by a spirochete transmitted by a bite from an infected tick that lives on deer. This tick exposure may have come from hiking or camping. Lyme disease if not treated may result in neurological disorders. There is not, however, any indication that the client has long-term Lyme disease or neurological changes. During the initial period after becoming infected the client may experience flu-like illnesses but there is no indication that this is the primary concern for the client. While appetite changes may result during an infection this is not the priority for the nurses questions.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.2: Develop questions to be used when completing the focused interview.

Question 8

Type: MCSA

The nurse is performing the Romberg test and asks the client to stand with the feet together and eyes closed. The nurse notes the findings are normal. Which of the following client responses occurred in this situation? The client:

1. Swayed from side to side.

2. Had minimal swaying.

3. Felt moderately dizzy.

4. Had complete loss of balance.

Correct Answer: 2

Rationale 1: The Romberg test is used to test coordination and equilibrium. A minimal amount of swaying is normal. Swaying from side to side is not a normal finding.

Rationale 2: The Romberg test is used to test coordination and equilibrium. A minimal amount of swaying is normal.

Rationale 3: The Romberg test is used to test coordination and equilibrium. During the test, the client is asked to stand with feet together and arms at the sides. A minimal amount of swaying is normal. The onset of dizziness is not a normal finding.

Rationale 4: The Romberg test is used to test coordination and equilibrium. A minimal amount of swaying is normal. A complete loss of balance is not a normal finding.

Global Rationale: The Romberg test is used to test coordination and equilibrium. During the test, the client is asked to stand with feet together and arms at the sides. The clients eyes are initially open. Then, the examiner will ask the client to close his eyes. The examiner will need to observe for swaying. A minimal amount of swaying is normal. Dizziness during the test is not a normal finding. Significant swaying from side to side and loss of balance are not normal findings and may indicate a cerebellar dysfunction.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system.

Question 9

Type: MCMA

The nurse is assessing a client that experienced a head injury and assigns a Glascow Coma Scale rating of 3. The nurse would correctly note which of the following for this client?

Standard Text: Select all that apply.

1. No response with eyes with commands

2. No verbal response

3. Pupil response sluggish

4. No motor movement

5. Pupils fixed and dilated

Correct Answer: 1,2,4

Rationale 1: No response with eyes with commands. The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. The lack of eye response, verbal response, and motor response indicate a score of 3 points.

Rationale 2: No verbal response. The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. The lack of eye response, verbal response, and motor response indicate a score of 3 points.

Rationale 3: Pupil response sluggish. The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. The lack of eye response, verbal response, and motor response indicate a score of 3 points. The lower the score, the more critical the clients condition. A score of 3 indicates the clients condition is grave. Pupil activity is not evaluated using the Glascow Coma Scale.

Rationale 4: No motor movement. The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. The lack of eye response, verbal response, and motor response indicate a score of 3 points. The lower the score, the more critical the clients condition. A score of 3 indicates the clients condition is grave.

Rationale 5: Pupils fixed and dilated. The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. The lack of eye response, verbal response, and motor response indicate a score of 3 points. The lower the score, the more critical the clients condition. A score of 3 indicates the clients condition is grave. Pupil activity is not evaluated using the Glascow Coma Scale.

Global Rationale: The Glascow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. The lack of eye response, verbal response and motor response indicate a score of 3 points. Lower scores indicate more critical conditions. A score of 3 indicates the clients condition is grave. Pupil activity is not evaluated using the Glascow Coma Scale.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system.

Question 10

Type: MCSA

The nurse is performing a neurological assessment and needs to test cranial nerves. The nurse asks the client to close both eyes and report when a touch with a wisp of cotton is felt. The nurse is assessing the function of which of the following cranial nerves?

1. Trigeminal nerve (cranial nerve V)

2. Abducens nerve (cranial nerve VI)

3. Facial nerve (cranial nerve VII)

4. Optic nerve (cranial nerve II)

Correct Answer: 1

Rationale 1: The cranial nerve V is responsible for facial sensations and may be assessed by a wisp of cotton on the face.

Rationale 2: The cranial nerve VI is related to vision.

Rationale 3: The cranial nerve VII is related to facial movements and the sensation of taste.

Rationale 4: The cranial nerve II is related to vision.

Global Rationale: The trigeminal nerve, cranial nerve V, is responsible for the facial sensations, sensory impulses from the tongue, lower teeth, skin of chin, and lower lip. The nerve also has motor functions including teeth clenching and movement of the mandible. The abducens nerve, cranial nerve VI, is related to vision. The facial nerve, cranial nerve VII, has responsibilities including facial expressions, the production of tears and salivary stimulation and is also associated with taste. The optic nerve, cranial nerve II, has the sensory function of vision.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system.

Question 11

Type: MCSA

The nurse in the photograph is performing an assessment on which of the following cranial nerves?

Screen Shot 2015-09-24 at 12.48.06 PM

1. Olfactory nerve (cranial nerve I)

2. Optic nerve (cranial nerve II)

3. Oculomotor nerve (cranial nerve III)

4. Trochlear nerve (cranial nerve IV)

Correct Answer: 1

Rationale 1: The sense of smell assessment is being demonstrated in the photograph. The olfactory nerve (cranial nerve I) is being evaluated.

Rationale 2: Cranial nerve II is the optic nerve. Assessment of cranial nerve II (optic nerve) would involve assessment of vision.

Rationale 3: Cranial nerve III (oculomotor nerve) involves the assessment of vision-related parameters.

Rationale 4: Cranial nerve IV (trochlear nerve) involves the assessment of vision related parameters.

Global Rationale: The sense of smell assessment is being demonstrated in the photograph. The olfactory nerve (cranial nerve I), which is responsible for the sense of smell, is being evaluated. Cranial nerve II is the optic nerve. Assessment of cranial nerve II (optic nerve) would involve assessment of vision. Cranial nerve III (oculomotor nerve) involves the assessment of papillary reactivity and the extrinsic muscles of the eyes. Cranial nerve IV (trochlear nerve) assessment would require assessing the movements of the eyes. This would include instructing the client to follow an object such as the examiners finger with the eyes.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system.

Question 12

Type: MCSA

Review the 2 photographs below. Which of the following cranial nerves is being evaluated by this activity being demonstrated?

Screen Shot 2015-09-24 at 12.48.42 PM

1. Trigeminal nerve (cranial nerve V)

2. Facial nerve (cranial nerve VII)

3. Vagus nerve (cranial nerve X)

4. Hypoglossal nerve (cranial nerve XII)

Correct Answer: 4

Rationale 1: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the tongue for swallowing, movement of food during eating, chewing and speech. The trigeminal nerve (cranial nerve V) is responsible for sensory impulses from the tongue, lower teeth, skin of the teeth and lower lip.

Rationale 2: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the tongue for swallowing, movement of food during eating, chewing and speech. The facial nerve (cranial nerve VII) is responsible for the sense of taste.

Rationale 3: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the tongue for swallowing, movement of food during eating, chewing and speech. The vagus nerve (cranial nerve X) innervates the muscles of the throat and mouth for swallowing and talking.

Rationale 4: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the tongue for swallowing, movement of food during eating, chewing, and speech.

Global Rationale: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the tongue for swallowing, movement of food during eating, chewing and speech. The trigeminal nerve (cranial nerve V) is responsible for facial sensation and temporal and massetter strength. The facial nerve (cranial nerve VII) is responsible for the sense of taste and facial expressions. The vagus nerve (cranial nerve X) innervates the muscles of the throat and mouth for swallowing and talking.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system.

Question 13

Type: MCSA

The nurse is examining a client experiencing vertigo and wants to perform the Romberg test. The nurse would correctly provide which set of instructions to the client?

1. Touch your finger to your nose, alternating hands.

2. Walk across the room by placing one foot in front of the other, heel to toes.

3. Walk on your toes, then on your heels, then on your toes again.

4. Stand with your feet together, arms at sides, and eyes open.

Correct Answer: 4

Rationale 1: The Romberg test is used to assess coordination and equilibrium. During the test the client is asked to stand with feet together, arms at sides, and eyes open. As the test progresses the client is asked to close her eyes. The amount of swaying done by the client once the eyes are closed is observed. Touching the finger to the nose with alternating hands is referred to as the finger-to-nose test and is used to assess coordination and equilibrium but is not the same as the Romberg test.

Rationale 2: Walking across the room in this manner describes tandem walking. This technique is used to observe gait.

Rationale 3: Walking in this manner enables the examiner to assess posture. The examiner should note the clients stance and the degree of stiffness or relaxation.

Rationale 4: The Romberg test is used to assess coordination and equilibrium. During the test the client is asked to close her eyes. The degree of swaying demonstrated is evaluated.

Global Rationale: The Romberg test is used to assess coordination and equilibrium. During the test the client is asked to stand with feet together, arms at sides, and eyes open. As the test progresses the client is asked to close her eyes. The amount of swaying done by the client once the eyes are closed is observed. Walking across the room by placing one foot in front of the other, heel to toes, describes tandem walking, which is used to observe gait. Posture is assessed by asking the client to walk on the toes, then on the heels. Touching the finger to the nose with alternating hands is referred to as the finger-to-nose test and is used to assess coordination and equilibrium but is not the same as the Romberg test.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system.

Question 14

Type: MCSA

The nurse is performing a neurological assessment on a client and needs to use stereognosis[0] Which of the following instructions would the nurse provide for the client?

1. Tell me if you feel one or two objects touching you with your eyes closed.

2. Identify the object in your hand with your eyes closed.

3. Identify the number being traced in your hand with your eyes closed.

4. Open and close your hand each time I tell you to.

Correct Answer: 2

Rationale 1: Stereognosis is the ability to identify an object without seeing it. It is illustrated by asking the client to identify objects placed in the hands with the eyes closed. Asking the client to identify the presence of objects touching them is not an example of the technique.

Rationale 2: Stereognosis is the ability to identify an object without seeing it. It is illustrated by asking the client to identify objects placed in the hands with the eyes closed.

Rationale 3: Stereognosis is the ability to identify an object without seeing it. It is illustrated by asking the client to identify objects placed in the hands with the eyes closed. Asking the client to identify the presence of objects touching them is not an example of the technique. Graphesthesia is the ability to perceive writing on the skin.

Rationale 4: Sterognosis is the ability to identify an object without seeing it. It is illustrated by asking the client to identify objects placed in the hands with the eyes closed. Asking the client to open and close the hand may be used to assess the ability to follow commands to assess hand strength.

Global Rationale: Stereognosis [0]is the ability to identify an object without seeing it. It is illustrated by asking the client to identify objects placed in the hands with the eyes closed. Asking the client to identify the presence of objects touching them is not an example of the technique. Graphesthesia is the ability to perceive writing on the skin. Asking the client to open and close the hand may be used to assess the ability to follow commands to assess hand strength.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system.

Question 15

Type: MCSA

The nurse performing reflex testing on a client uses the reflex hammer to gently strike the forearm about two inches above the wrist. The nurse is assessing which of the following reflexes?

1. Brachioradialis

2. Biceps

3. Triceps

4. Achilles

Correct Answer: 1

Rationale 1: The brachioradialis reflex is initiated by striking the forearm just above the wrist. The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is initiated by striking just above the olecranon process. The Achilles reflex is initiated by dorsiflexion of the foot and striking the Achilles tendon.

Rationale 2: The brachioradialis reflex is initiated by striking the forearm just above the wrist. The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is initiated by striking just above the olecranon process. The Achilles reflex is initiated by dorsiflexion of the foot and striking the Achilles tendon.

Rationale 3: The brachioradialis reflex is initiated by striking the forearm just above the wrist. The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is initiated by striking just above the olecranon process. The Achilles reflex is initiated by dorsiflexion of the foot and striking the Achilles tendon.

Rationale 4: The brachioradialis reflex is initiated by striking the forearm just above the wrist. The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is initiated by striking just above the olecranon process. The Achilles reflex is initiated by dorsiflexion of the foot and striking the Achilles tendon.

Global Rationale: The brachioradialis reflex is initiated by striking the forearm just above the wrist. The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is initiated by striking just above the olecranon process. The Achilles reflex is initiated by dorsiflexion of the foot and striking the Achilles tendon.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system.

Question 16

Type: MCSA

The nurse is admitting a client with suspected meningitis and notes a positive Brudzinskis sign has been noted in the history and physical. To validate this assessment finding, the nurse would note which of the following?

1. Seizure activity

2. Neck pain and stiffness

3. Flexion of the legs and thighs

4. Neck extension

Correct Answer: 3

Rationale 1: Brudzinskis sign is assessed in clients suspected of having meningitis. To assess for this sign the client is placed in a supine position and assisted to flex the neck. In a positive test the legs and thighs will also flex. Seizure activity may be seen in meningitis but seizure activity does not constitute a positive Brudzinskis sign.

Rationale 2: Brudzinskis sign is assessed in clients suspected of having meningitis. To assess for this sign the client is placed in a supine position and assisted to flex the neck. In a positive test the legs and thighs will also flex. Neck pain and stiffness may be noted with meningitis but this is referred to as nuchal rigidity.

Rationale 3: Brudzinskis sign is assessed in clients suspected of having meningitis. To assess for this sign the client is placed in a supine position and assisted to flex the neck. In a positive test the legs and thighs will also flex.

Rationale 4: Neck extension is not associated with Brudzinskis sign.

Global Rationale: Brudzinskis sign is assessed in clients suspected of having meningitis. To assess for this sign the client is placed in a supine position and assisted to flex the neck. In a positive test the legs and thighs will also flex. Seizure activity may be seen in meningitis but seizure activity does not constitute a positive Brudzinskis sign. Neck pain and stiffness may be noted with meningitis but this is referred to as nuchal rigidity. It does not constitute a positive Brudzinskis sign. Neck extension is not associated with a positive Brudzinskis sign.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system.

Question 17

Type: MCSA

The nurse is assessing cranial nerve XI (spinal accessory). Which of the following statements would the nurse say to the client?

1. Shrug your shoulders and turn your head against my hand.

2. Stick out your tongue and move it from side to side.

3. Taste these foods and decide which is sweet and which is sour.

4. Smell these items and identify what they are.

Correct Answer: 1

Rationale 1: The spinal accessory nerve (cranial nerve XI) controls shoulder and neck movements. The examiner planning to test this nerve should ask the client to shrug the shoulders and turn the head.

Rationale 2: The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the tongue.

Rationale 3: The facial nerve (cranial nerve VII) is responsible for the sense of taste.

Rationale 4: Smell is controlled by the olfactory nerve (cranial nerve I).

Global Rationale: The spinal accessory nerve (cranial nerve XI) controls shoulder and neck movements. The examiner planning to test this nerve should ask the client to shrug the shoulders and turn the head. The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the tongue. The facial nerve (cranial nerve VII) is responsible for the sense of taste and symmetrical facial movements. Smell is controlled by the olfactory nerve (cranial nerve I).

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system.

Question 18

Type: MCMA

The nurse is performing a neurological assessment and needs to assess for vibration, as well as sharp and dull sensation. The nurse would use which of the following objects to obtain this information?

Standard Text: Select all that apply.

1. Tuning fork

2. Paper clip

3. Safety pin

4. Cotton ball

5. Tongue blade

Correct Answer: 1,3

Rationale 1: Tuning fork. To test for sharp and dull sensation, areas of the clients skin are touched with the sharp and blunt ends of a safety pin. The client then verbalizes if the sensation is dull or sharp. Vibration is tested by striking a tuning fork and placing it on bony parts of the clients body.

Rationale 2: Paper clip. To test for sharp and dull sensation, areas of the clients skin are touched with the sharp and blunt ends of a safety pin. The client then verbalizes if the sensation is dull or sharp. Vibration is tested by striking a tuning fork and placing it on bony parts of the clients body.

Rationale 3: Safety pin. To test for sharp and dull sensation, areas of the clients skin are touched with the sharp and blunt ends of a safety pin. The client then verbalizes if the sensation is dull or sharp. Vibration is tested by striking a tuning fork and placing it on bony parts of the clients body.

Rationale 4: Cotton ball. The trigeminal nerve (cranial nerve V) may be evaluated by using a wisp of cotton to touch the face.

Rationale 5: Tongue blade. The gag reflex may be evaluated by using a tongue blade.

Global Rationale: To test for sharp and dull sensation, areas of the clients skin are touched with the sharp and blunt ends of a safety pin. The client then verbalizes if the sensation is dull or sharp. Vibration is tested by striking a tuning fork and placing it on bony parts of the clients body. The paper clip may be used to assess for the ability to determine the identity of an object unseen. A cotton ball may be used to assess sensation when evaluating the facial nerve. A tongue blade would be used to assess the gag reflex and the movements of the tongue.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.3: Describe the techniques required for assessment of the nervous system.

Question 19

Type: MCSA

The nurse has assessed a client and notes diminished reflexes. The nurse would correctly document which of the following?

1. 4+/0-4+

2. 3+/0-4+

3. 2+/0-4+

4. 1+/0-4+

Correct Answer: 1

Rationale 1: 4+ Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive.

Rationale 2: 3+ Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive.

Rationale 3: 2+ Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive.

Rationale 4: 1+ Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive.

Global Rationale: Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment of the neurologic system.

Question 20

Type: MCSA

The nurse is interviewing a client and notes that the left eyelid is drooping. The nurse would correctly chart which of the following conditions?

1. Ptosis

2. Nystagmus

3. Strabismus

4. Myopia

Correct Answer: 1

Rationale 1: Ptosis, or a dropped lid, is usually related to weakness of the muscles.

Rationale 2: Nystagmus is an involuntary movement of the eyeball.

Rationale 3: Strabismus causes deviation of one or both eyes and is due to lack of muscular coordination.

Rationale 4: Myopia is a visual disturbance in which the individual is unable to see objects that are at a distance.

Global Rationale: Ptosis, or a dropped lid, is usually related to weakness of the muscles. Nystagmus is an involuntary movement of the eyeball. Strabismus causes deviation of one or both eyes and is due to lack of muscular coordination. Myopia is a visual disturbance in which the individual is unable to see objects that are at a distance.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment of the neurologic system.

Question 21

Type: MCSA

The nurse observes drainage from a clients ears after a head injury, and suspects a cerebral spinal fluid (CSF) leak. Which of the following descriptions would best support this finding?

1. Yellow without sediment

2. Blood-tinged without sediment

3. Clear, colorless

4. Pink without sediment

Correct Answer: 3

Rationale 1: It is important to recognize CSF as clear and colorless. Due to its appearance, it can be mistaken for normal drainage such as rhinorrhea. Yellow drainage is not consistent with cerebral spinal fluid.

Rationale 2: It is important to recognize CSF as clear and colorless. Due to its appearance, it can be mistaken for normal drainage such as rhinorrhea. Blood-tinged fluid is not consistent with cerebral spinal fluid.

Rationale 3: It is important to recognize CSF as clear and colorless. Due to its appearance, it can be mistaken for normal drainage such as rhinorrhea.

Rationale 4: It is important to recognize CSF as clear and colorless. Pink drainage without sediment is not consistent with cerebral spinal fluid.

Global Rationale: It is important to recognize CSF as clear and colorless. Due to its appearance, it can be mistaken for normal drainage such as rhinorrhea. Yellow drainage is not consistent with normal cerebral spinal fluid. Blood-tinged fluid is not consistent with normal cerebral spinal fluid. Pink drainage without sediment is not consistent with cerebral spinal fluid.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment of the neurologic system.

Question 22

Type: MCSA

The nurse notes that a client has difficulty with ambulation due to an unsteady gait. The nurse would correctly document this finding as which of the following?

1. Flaccidity

2. Paralysis

3. Hemiparesis

4. Ataxia

Correct Answer: 4

Rationale 1: Flaccidity refers to muscle tone. The flaccid body part is not toned but is limp.

Rationale 2: Paralysis refers to the inability to move parts of the body.

Rationale 3: Hemiparesis refers to a weakness on one side of the body.

Rationale 4: Ataxia refers to the loss of balance or coordination.

Global Rationale: Ataxia refers to loss of balance and/or coordination. Flaccidity refers to muscle tone. Paralysis refers to the inability to move parts of the body. Hemiparesis refers to a weakness on one side of the body.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment of the neurologic system.

Question 23

Type: MCSA

The nurse is interviewing a client that states he does not have any feeling on right side of the body. After confirmation of this subjective data, the nurse would correctly document which of the following?

1. Anesthesia

2. Analgesia

3. Hypalgesia

4. Hypoesthesia

Correct Answer: 1

Rationale 1: Anesthesia is the inability to perceive the sense of touch. Analgesia is the absence of painful stimuli, while hypalgesia is a decreased pain sensation. Hypoesthesia is a decreased, but not absent, sensation.

Rationale 2: Anesthesia is the inability to perceive the sense of touch. Analgesia is the absence of painful stimuli, while hypalgesia is a decreased pain sensation. Hypoesthesia is a decreased, but not absent, sensation.

Rationale 3: Anesthesia is the inability to perceive the sense of touch. Analgesia is the absence of painful stimuli, while hypalgesia is a decreased pain sensation. Hypoesthesia is a decreased, but not absent, sensation.

Rationale 4: Anesthesia is the inability to perceive the sense of touch. Analgesia is the absence of painful stimuli, while hypalgesia is a decreased pain sensation. Hypoesthesia is a decreased, but not absent, sensation.

Global Rationale: Anesthesia is the inability to perceive the sense of touch. Analgesia is the absence of painful stimuli, while hypalgesia is a decreased pain sensation. Hypoesthesia is a decreased, but not absent, sensation.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment of the neurologic system.

Question 24

Type: MCSA

The nurse is admitting a client with suspected meningitis. During the assessment, the nurse asks the client to flex the chin down toward the chest. The client verbalizes pain and stiffness during this action. The nurse would document this as which of the following?

1. Muscle spasms

2. Neck strain

3. Nuchal rigidity

4. Brudzinskis sign

Correct Answer: 3

Rationale 1: Nuchal rigidity occurs with meningeal irritation, which will cause pain and neck stiffness. The presence of muscle spasms are not associated with meningitis and are not elicited in this manner.

Rationale 2: Neck strain is not associated with meningitis. The assessment of neck strain would not involve having the client flex the chin toward the chest.

Rationale 3: Nuchal rigidity occurs with meningeal irritation, which will cause pain and neck stiffness.

Rationale 4: Brudzinskis sign is assessed in clients suspected of having meningitis. The sign is present when neck flexion causes flexion of the legs and thighs

Global Rationale: Nuchal rigidity occurs with meningeal irritation, which will cause pain and neck stiffness. The presence of muscle spasms are not associated with meningitis and are not elicited in this manner. Neck strain is not associated with meningitis. The assessment of neck strain would not involve having the client flex the chin toward the chest. Brudzinskis sign is assessed in clients suspected of having meningitis. The sign is present when neck flexion causes flexion of the legs and thighs.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment of the neurologic system.

Question 25

Type: MCSA

While interviewing a client the nurse notes the clients eyes moving involuntarily. The nurse would correctly document which of the following findings?

1. Nystagmus

2. Presbyopia

3. Anosmia

4. Polyneuritis

Correct Answer: 1

Rationale 1: Nystagmus is an abnormal, involuntary eye movement.

Rationale 2: Presbyopia is an eye disorder in which the individual loses the ability to see objects that are near.

Rationale 3: Anosmia refers to the absence of the sense of smell.

Rationale 4: Polyneuritis refers to nerve inflammation.

Global Rationale: Nystagmus is an involuntary eye movement. Presbyopia is visual disturbances. Polyneuritis refers to nerve inflammation. Anosmia refers to the absence of smell.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 24.4: Differentiate normal from abnormal findings in physical assessment of the neurologic system.

Question 26

Type: MCSA

The nurse notes fanning of the toes when the sole of the foot is stimulated during assessment of the plantar reflex. The nurse would correctly chart which of the following?

1. Hyperreflexia

2. Babinski response

3. Brudzinski sign

4. Nuchal rigidity

Correct Answer: 2

Rationale 1: Hyperreflexia refers to a reflex that is abnormally strong.

Rationale 2: The Babinski response is fanning of the toes with the great toe pointing downward when the sole of the foot is stimulated. This response is considered abnormal in adults.

Rationale 3: Brudzinski sign refers to flexion of the legs and thighs when the neck is flexed and is an assessment used to confirm meningitis.

Rationale 4: Nuchal rigidity refers to stiffness of the neck and is most often seen in meningitis.

Global Rationale: The Babinski response is fanning of the toes with the great toe pointing downward when the sole of the foot is stimulated. This response is considered abnormal in adults. The findings described do not support hyperreflexia. Hyperreflexia refers to a reflex that is abnormally strong. Brudzinski sign refers to flexion of the legs and thighs when the neck is flexed and is an assessment used to confirm meningitis. Nuchal rigidity refers to stiffness of the neck and is most often seen in meningitis.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 24.5: Describe developmental, cultural, psychosocial, and environmental variations in assessment techniques and findings of the neurologic system.

Question 27

Type: MCSA

The nurse is preparing a neurological health seminar for the staff on the unit. Which of the following statements would the nurse include in the teaching plan?

1. Older adults experience fewer accidents and injuries.

2. Alcohol or drug use increases the risk for accidents and injury.

3. Head injuries are more common in adults than children.

4. Epilepsy occurs only in children under age 15.

Correct Answer: 2

Rationale 1: Older adults experience more accidents and injuries.

Rationale 2: Alcohol or drug use does increase the risk for accidents and injury and neurologic disorders.

Rationale 3: Head injuries are more common in children than adults.

Rationale 4: Epilepsy occurs across the age span.

Global Rationale: Alcohol or drug use does increase the risk for accidents and injury and neurologic disorders. Older adults experience more accidents and injury. Head injuries are more common in children than adults. Epilepsy occurs across the age span.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24.5: Describe developmental, cultural, psychosocial, and environmental variations in assessment techniques and findings of the neurologic system.

Question 28

Type: MCSA

The nurse is reviewing the history and physical on a client and notes a history of syncope. The nurse would implement which of the following for this client?

1. Soft diet

2. Seizure precautions

3. Fall precautions

4. Intake and output

Correct Answer: 3

Rationale 1: Syncope is a sudden, brief loss of consciousness, and the nurse would need to provide safety for a client experiencing this condition. Dietary changes may be indicated for problems with chewing or swallowing but not for syncope.

Rationale 2: Syncope is a sudden, brief loss of consciousness, and the nurse would need to provide safety for a client experiencing this condition. Seizure precautions may be indicated for an individual with a seizure-related disorder but not for the presence of syncope.

Rationale 3: Syncope is a sudden, brief loss of consciousness, and the nurse would need to provide safety for a client experiencing this condition.

Rationale 4: Intake and output may be assessed for a variety of conditions but are not directly needed by the client experiencing episodes of syncope.

Global Rationale: Syncope is a sudden, brief loss of consciousness, and the nurse would need to provide safety for a client experiencing this condition. Dietary changes may be indicated for problems with chewing or swallowing but not for syncope. Seizure precautions may be indicated for an individual with a seizure-related disorder but not for the presence of syncope. Intake and output may be indicated for a variety of medical conditions but are not indicated for the presence of syncope.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 24.7: Apply critical thinking in selected simulations related to physical assessment of the neurologic system.

Question 29

Type: MCSA

The nurse is observing a clients ambulation abilities and notes a scissors gait. The nurse would suspect which of the following disorders in this client?

1. Parkinsons disease

2. Multiple sclerosis

3. Myasthenia gravis

4. Muscular dystrophy

Correct Answer: 2

Rationale 1: The client with Parkinsons disease displays stooped posture a shuffling gait. This is known as a festination gait.

Rationale 2: A scissors gait is characterized by spastic lower limb movement with stiffness and jerkiness. The knees come together, the legs come in front of each other, and the legs are abducted as short, slow steps are taken. This gait is associated with multiple sclerosis.

Rationale 3: The client with myasthenia gravis has muscle weakness, and facial abnormalities such as ptosis are consistent with the condition. The client with muscular dystrophy has muscle weakness and may present with a waddling gait or walk on the toes to promote balance.

Rationale 4: The client with muscular dystrophy has muscle weakness and may present with a waddling gait or walk on the toes to promote balance.

Global Rationale: A scissors gait is characterized by spastic lower limb movement with stiffness and jerkiness. The knees come together, the legs come in front of each other, and the legs are abducted as short, slow steps are taken. This gait is associated with multiple sclerosis. The client with Parkinsons disease displays stooped posture a shuffling gait. This is known as a festination gait. The client with myasthenia gravis has muscle weakness, and facial abnormalities such as ptosis are consistent with the condition. The client with muscular dystrophy has muscle weakness and may present with a waddling gait or walk on the toes to promote balance.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.7: Apply critical thinking in selected simulations related to physical assessment of the neurologic system.

Question 30

Type: MCSA

The nurse is assessing cognitive function in a client who experienced a cerebral vascular accident. The nurse should focus on which of the following?

1. Ability to smell items while eyes are closed

2. Orientation to time, place, and person

3. Ability to walk with a smooth, steady gait

4. Ability to speak clearly

Correct Answer: 2

Rationale 1: Cognitive function refers to mental abilities. The assessment of mental abilities may be performed by determining the clients orientation to time, place, and person. The ability to smell objectives while the eyes are closed is a means of assessing cranial nerve function.

Rationale 2: Cognitive function refers to mental abilities. The assessment of mental abilities may be performed by determining the clients orientation to time, place, and person.

Rationale 3: Cognitive function refers to mental abilities. The assessment of mental abilities may be performed by determining the clients orientation to time, place, and person. The ability to walk smoothly with a steady gait and to speak clearly are items that may be included in the assessment of a client who has had a cerebral vascular accident but these reflect motor function and do not reflect cognitive abilities.

Rationale 4: Cognitive function refers to mental abilities. The assessment of mental abilities may be performed by determining the clients orientation to time, place, and person. The ability to walk smoothly with a steady gait and to speak clearly are items that may be included in the assessment of a client who has had a cerebral vascular accident but these reflect motor function and do not reflect cognitive abilities.

Global Rationale: Cognitive function refers to mental abilities. The assessment of mental abilities may be performed by determining the clients orientation to time, place, and person. The ability to smell objectives while the eyes are closed is a means of assessing cranial nerve function. The ability to walk smoothly with a steady gait and to speak clearly are items that may be included in the assessment of a client who has had a cerebral vascular accident but these reflect motor function and do not reflect cognitive abilities.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.7: Apply critical thinking in selected simulations related to physical assessment of the neurologic system.

Question 31

Type: MCSA

The nurse is providing discharge instructions to the mother of a child admitted for fever of unknown origin. Which of the following statements, if made by the mother, would indicate the need for further instruction?

1. I should use Tylenol or aspirin to bring down the temperature.

2. I should contact the doctor if I cannot wake up my child.

3. I should observe how much my child urinates.

4. I should monitor my childs intake of fluids throughout the day.

Correct Answer: 1

Rationale 1: Aspirin should not be administered to ill children due to the risk of Reyes syndrome.

Rationale 2: An inability to wake the child would indicate a worsening condition warranting contact with the healthcare provider.

Rationale 3: The child with an elevated temperature is at risk for dehydration. Observation of oral intake and urinary output will aid in determining fluid status.

Rationale 4: The child with an elevated temperature is at risk for dehydration. Observation of oral intake and urinary output will aid in determining fluid status.

Global Rationale: Aspirin should not be administered to ill children due to the risk of Reyes syndrome. Reyes syndrome is a condition of unknown etiology that may strike children. The disease affects the major organs of the body. The remaining statements are correct and should be included in the teaching plan for a child with a febrile illness. An inability to wake the child would indicate a worsening condition warranting contact with the healthcare provider. The child with an elevated temperature is at risk for dehydration. Observation of oral intake and urinary output will aid in determining fluid status.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 24.7: Apply critical thinking in selected simulations related to physical assessment of the neurologic system.

Question 32

Type: MCMA

The nurse is reviewing questions to include in a focused assessment on a client who has presented to the clinic with complaints of back pain. Which of the following questions should be included in the interview?

Standard Text: Select all that apply.

1. How long have you been experiencing this pain?

2. What activities seem to increase your pain?

3. Do any members of your family have neurological problems?

4. What things do you do to relieve your pain?

5. Are you able to perform your employment responsibilities since the pain began?

Correct Answer: 1,2,3,4,5

Rationale 1: How long have you been experiencing this pain? The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being reviewed. When investigating pain the nurse will need to assess characteristics of the pain, including duration.

Rationale 2: What activities seem to increase your pain? The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being reviewed. Investigation of the pain will include information about factors associated with both activities that increase pain and those that relieve it.

Rationale 3: Do any members of your family have neurological problems? The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being reviewed. Certain neurological problems may have familial links and this potential should be investigated.

Rationale 4: What things do you do to relieve your pain? The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being reviewed. Activities that will relieve the pain should be included in the focused assessment.

Rationale 5: Are you able to perform your employment responsibilities since the pain began? The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being reviewed. The impact of the pain on the clients abilities to manage normal activities is included in the focused assessment.

Global Rationale: The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being reviewed. When considering neurological concerns questions should include those about symptoms, pain, behaviors associated with the complaints, and the impact of the pain.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24.2: Develop questions to be used when completing the focused interview.

Question 33

Type: MCSA

The community health nurse is preparing a program geared toward primary prevention of hypertension. When preparing the program, what activities will aid the nurse in meeting the goals of primary prevention?

1. Providing dietary counseling for clients with hypertension

2. Offering free blood pressure screening to participants

3. Having a contest for participants to win an automatic blood pressure cuff for home use

4. Providing literature to discuss modifiable risk factors

Correct Answer: 4

Rationale 1: The focus of secondary prevention is the reduction of risks and complications to the client who already has a disorder. Providing dietary counseling is an example of secondary prevention.

Rationale 2: The focus of secondary prevention is the reduction of risks and complications to the client who already has a disorder. Providing blood pressure screening is an example of secondary prevention.

Rationale 3: The focus of secondary prevention is the reduction of risks and complications to the client who already has a disorder. Providing contests for a free blood pressure cuff is an example of secondary prevention.

Rationale 4: Primary prevention activities seek to reduce the incidence of disease. There are risk factors associated with hypertension. Change in modifiable risk factors may result in the reduction of disease incidence.

Global Rationale: Primary prevention activities seek to reduce the incidence of disease. There are risk factors associated with hypertension. Change in modifiable risk factors may result in the reduction of disease incidence. The focus of secondary prevention is the reduction of risks and complications to the client who already has a disorder. Providing dietary counseling, blood pressure screenings, and contests for a free blood pressure cuff are examples of secondary prevention.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24.6: Discuss the focus areas regarding neurologic health as stated in the Healthy People 2020 initiatives.

Question 34

Type: MCSA

The nurse is providing education to a group of pregnant women. The nurse should stress which of the following as the greatest tool in the prevention of low-birth-weight babies?

1. Early prenatal care

2. Eating a balanced diet

3. Avoiding stress

4. Regular exercise

Correct Answer: 1

Rationale 1: Obtaining prenatal care is the most important activity a pregnant woman can engage in to aid in providing a positive outcome for an unborn child. Prenatal care will include screening for complications of pregnancy, education, and monitoring of health status.

Rationale 2: Obtaining prenatal care is the most important activity a pregnant woman can engage in to aid in providing a positive outcome for an unborn child. Prenatal care will include screening for complications of pregnancy, education, and monitoring of health status. A balanced diet is important during pregnancy but not all complications of pregnancy are nutrition related.

Rationale 3: Obtaining prenatal care is the most important activity a pregnant woman can engage in to aid in providing a positive outcome for an unborn child. Prenatal care will include screening for complications of pregnancy, education, and monitoring of health status. Avoidance of stress is beneficial during pregnancy but will not prevent the majority of pregnancy related complications.

Rationale 4: Obtaining prenatal care is the most important activity a pregnant woman can engage in to aid in providing a positive outcome for an unborn child. Prenatal care will include screening for complications of pregnancy, education, and monitoring of health status. With monitoring and approval of the healthcare provider, regular exercise is beneficial to the pregnant woman. Exercise, however, does not prevent the greatest number of pregnancy related complications.

Global Rationale: Obtaining prenatal care is the most important activity a pregnant woman can engage in to aid in providing a positive outcome for an unborn child. Prenatal care will include screening for complications of pregnancy, education, and monitoring of health status. A balanced diet, avoidance of stress, and exercise are beneficial but not as important as obtaining early, regular prenatal care.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24.6: Discuss the focus areas regarding neurologic health as stated in the Healthy People 2020 initiatives.

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