Chapter 33- Patient Assessment- Nervous System My Nursing Test Banks

 

1.

The nurse is conducting tests of a patients cerebellar synchronization of movement with balance. What result of the finger-to-nose test would indicate cerebellar dysfunction?

A)

The patient has trouble understanding the nurses instructions.

B)

The patient cannot reach his or her nose due to restricted range of motion in the elbow.

C)

The patient overshoots when trying to touch his or her nose.

D)

The patient cannot touch his or her nose due to a trembling hand.

2.

A neurologist who is testing a patient for neurological deficits has her close her eyes and then hands her a stethoscope. He asks her to identify the object by touch, but she cannot do so. The nurse, observing this result, should suspect possible damage to which part of the brain?

A)

Cerebellum

B)

Temporal lobe

C)

Frontal lobe

D)

Parietal lobe

3.

A nurse is assessing the plantar reflex in a patient. Which of the following results would indicate abnormal response and a possible lesion in the pyramidal tract? Select all that apply.

A)

Plantar flexion of all toes

B)

Dorsiflexion of the big toe with fanning of the other toes

C)

No response at all

D)

Dorsiflexion of the big toe without fanning of the other toes

E)

Ticklishness

4.

A patient admitted to the ICU following a car accident in which she suffered multiple traumatic injuries. She has a fever of 101F and complains of headache. When the physician tries to examine her eyes with a bright light, she jerks away. The nurse suspects meningeal irritation. What other signs would likely accompany this condition? Select all that apply.

A)

Nuchal rigidity

B)

Drainage of cerebrospinal fluid from the nose

C)

Drainage of cerebrospinal fluid from the ear

D)

Bruising over the mastoid areas

E)

Pain in the neck when the thigh is flexed and the leg is extended at the knee

F)

Involuntary flexion of the hips when the neck is flexed toward the chest

5.

A patient suffered damage to cranial nerve VIII in a jet ski accident. What symptom or symptoms should the nurse tell the patient to expect? Select all that apply.

A)

Loss of the sense of smell

B)

Partial blindness in one eye

C)

Paralysis of face muscles on one side of the face

D)

Tinnitus

E)

Dizziness

F)

Inhibited ability to move the tongue

6.

A patient has trouble shrugging his shoulders and turning his head from side to side against resistance. Which nerve should the nurse suspect to be involved?

A)

Cranial nerve XI

B)

Cranial nerve XII

C)

Cranial nerve X

D)

Cranial nerve IX

7.

A patient begins to demonstrate loss of consciousness as a result of intracranial pressure. He also demonstrates bradycardia and decreased irregular respirations. Which of the following best describes the identified manifestations?

A)

Rhinorrhea

B)

Meningeal irritation

C)

Cheyne-Stokes respirations

D)

Cushings triad

8.

A patient is preparing to undergo magnetic resonance imaging for possible diagnosis of cerebral infarction. What is the nursing priority in preparing the patient for this diagnostic study?

A)

Checking the patients history for renal insufficiency, which could complicate use of a contrast medium.

B)

Confirming that the patient does not have any ferrous surgical clips or implants.

C)

Determining whether the patient is on anticoagulant therapy, which would be a contraindication.

D)

Preparing an 18-gauge needle for insertion.

9.

A patient is undergoing myelography for assessment of a spinal cord tumor. How should the nurse position the patient for this procedure?

A)

Head elevated 30 to 45 degrees

B)

Head lowered below the level of the feet

C)

Side-lying with the patients bed level

D)

Prone with the patients bed flat

10.

Following a lumbar puncture for CSF analysis, a patient with elevated intracranial pressure develops a headache, nuchal rigidity, fever, and difficulty voiding. What intervention should the nurse expect?

A)

Administration of IV fluids

B)

Administration of antibiotic

C)

Injection of blood into the dura

D)

Cardiopulmonary resuscitation

11.

The nurse is performing a physical examination on a patient with neurologic disease. What finding from the examination is the most indicative of diminished cerebral hemisphere functioning?

A)

Deteriorating level of consciousness

B)

Positive Romberg test

C)

Unequal pupillary response

D)

Glasgow Coma Scale score of 15

12.

While assessing motor function, the nurse applies pressure to a toenail. What patient response is most normal?

A)

Extension of both feet

B)

Flexion of knee and ankle

C)

Extension of one or both arms

D)

Kicking the nurses hand away

13.

The patient has been in a motor vehicle crash and is in the critical care unit with severe brain injury. She is comatose but when painful stimuli are applied she extends, adducts, and hyperpronates her upper extremities and has plantarflexion of the feet. This action is called what?

A)

Decorticate posturing

B)

Decerebrate posturing

C)

Clonic-tonic activity

D)

Flacidity

14.

When describing a patients responsiveness, the nurse uses the term obtunded. What is the most accurate meaning of this term?

A)

Unable to arouse with any stimulus

B)

Sedated with intravenous medications

C)

Having inborn mental retardation

D)

Arousable but drowsy and slow to respond

15.

During a neurologic examination, the nurse finds bilateral pronator drift and diminished ability to raise legs against resistance. These findings are consistent with what neurologic deficit?

A)

Damage to motor neuron pathways

B)

Hyperthyroidism

C)

Demyelinization of afferent fibers

D)

Cerebral cortex hypoperfusion

16.

As part of the neurologic examination, the nurse instructs the patient to perform a Romberg test. What nursing action best provides for patient safety if the results are abnormal?

A)

Have suction equipment on hand

B)

Be prepared to catch the patient if he or she falls

C)

Have the patient perform the test in a seated position

D)

Have the patient perform the finger-to-nose test before this test

17.

Although awake and alert, a patient who has experienced a neurologic insult is having difficulty maintaining a patent airway and requires frequent jaw thrust maneuvers. What neurologic damage is this finding most closely associated with?

A)

High cervical spinal cord lesion

B)

Cerebral infarction of the brainstem

C)

Damage to the eighth cranial nerve

D)

Damage to the second and third cranial nerves

18.

During a craniotomy, the patient experienced peripheral damage to cranial nerve VII, resulting in diminished movement of the left side of the face. What nursing action demonstrates best understanding of the effect of this lesion on the patient?

A)

Referral for speech therapy and swallowing assessment

B)

Use of ocular moisturizers

C)

Teaching about falling and syncope risks

D)

Referral for evaluation for a hearing aid

19.

One of the major goals of therapy for a patient with a head injury is to control rising intracranial pressure (ICP). What assessment data would first cause the nurse to suspect rising ICP?

A)

Deteriorating level of consciousness

B)

Brisk pupils with equal reactivity

C)

Absence of speech secondary to sedative use

D)

Narrow pulse pressure and hypotension

20.

A patient with a suspected cervical spine fracture is undergoing computed tomography (CT) of the cervical spine for definitive diagnosis. During the procedure, what is the nursing priority?

A)

Protection of cervical spine stability

B)

Reassurance and anxiety reduction

C)

Explanation of the reason for the test

D)

Evaluation for allergic response to contrast medium

21.

A patient with serious neurologic trauma is being evaluated for brain death using cerebral blood flow studies. What is the most accurate information the nurse can provide when discussing the test with the family?

A)

If the test shows no blood flow to the cerebral hemispheres, brain death is definite.

B)

If the test shows adequate flow to the cerebral hemispheres, the brain is viable.

C)

The test will give a more accurate measurement of intracranial pressure.

D)

The test is performed only after all sedative and pain medications are discontinued.

22.

The patient is undergoing myelography to evaluate his back pain. What are appropriate nursing interventions? Select all that apply.

A)

Elevate the head of the bed to 30 to 45 degrees.

B)

Restrict total fluid intake.

C)

Avoid phenothiazines.

D)

Institute seizure precautions.

E)

Initiate ambulation immediately.

F)

Turn, cough, and deep breathe every 2 hours.

Answer Key

1.

C

2.

D

3.

B, D

4.

A, E, F

5.

D, E

6.

A

7.

D

8.

B

9.

A

10.

C

11.

A

12.

D

13.

B

14.

D

15.

A

16.

B

17.

A

18.

B

19.

A

20.

A

21.

A

22.

A, C, D

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