Chapter 34Assessment of Neurological Function My Nursing Test Banks

Chapter 34Assessment of Neurological Function

MULTIPLE CHOICE

1.A client is scheduled for surgery to fuse the vertebra in the lumbar region of the spine. The nurse should instruct the client that the number of vertebra being affected by this surgery would be:

1.

7.

2.

12.

3.

5.

4.

4.

ANS: 3

There are 5 vertebra in the lumbar spine region. This is what the nurse should instruct the client as being fused during the surgery. There are 7 cervical vertebra, 12 thoracic, and 4 coccygeal fused into one.

PTS: 1 DIF: Apply REF: Central Nervous System: Bones

2.A client has sustained a cerebral injury that is applying pressure to the corpus callosum. The nurse realizes that which of the following might occur with this client?

1.

Temporary blindness

2.

Temporary inability to talk

3.

Temporary inability to walk

4.

Temporary miscommunication between the sides of the brain

ANS: 4

The corpus callosum allows the two hemispheres of the brain to communicate. An injury to this area could cause the client to experience temporary miscommunication between the sides of the brain. Pressure on this region may or may not lead to temporary blindness, the inability to talk, or the inability to walk.

PTS: 1 DIF: Analyze REF: Brain

3.A client is recovering from an injury to the frontal lobe of the brain. The nurse realizes that which of the following will be affected by this injury?

1.

Higher intellectual functioning

2.

Visual perception

3.

Coordination

4.

Respiratory rate

ANS: 1

The major function of the frontal lobe of the cerebral hemisphere is high-level cognitive activity. This is what will be affected in the client with an injury to the frontal lobe. Visual perception occurs in the occipital lobe. Coordination occurs from the cerebellum. Respiratory rate is controlled by the brainstem.

PTS: 1 DIF: Analyze REF: Figure 34-6 The Lobes of the Brain

4.A client is recovering from a cerebral bleed which is placing pressure on the hypothalamus. Which of the following will the nurse most likely assess in this client?

1.

Variations in body temperature

2.

Blindness

3.

Alteration in speech

4.

Uncoordinated body movements

ANS: 1

The hypothalamus regulates temperature of the body. Pressure from a cerebral bleed on the hypothalamus could cause variations in the clients body temperature. Pressure to the hypothalamus will not cause blindness, alterations in speech, or uncoordinated body movements.

PTS:1DIF:ApplyREFiencephalon

5.A client recovering from a cerebral vascular accident is having difficulty remembering how to chew food. The nurse realizes that which of the following cranial nerves could be affected in this client?

1.

IX

2.

X

3.

XI

4.

V

ANS: 4

Cranial nerve V or Trigeminal nerve has three branches. The mandibular branch innervates the muscles for chewing. Cranial nerve IX glossopharyngeal innervates the muscles of swallowing. Cranial nerve X innervates the gastrointestinal tract through parasympathetic tracts of the nerve. Cranial nerve XI innervates the muscles of the neck for movement.

PTS: 1 DIF: Analyze REF: Table 34-2 Cranial Nerves

6.When utilizing the Glasgow Coma Scale during an assessment, the nurse identifies that the client is making incomprehensible sounds. This assessment finding would be included in which part of the assessment?

1.

Eye opening

2.

Verbal response

3.

Best motor response

4.

Mentation

ANS: 2

The assessment finding of incomprehensible sounds would be documented within the verbal response section of the Glasgow Coma Scale. Eye opening would assess if the client opens the eyes in response to stimuli. Best motor response would assess the stimuli needed to have the client move an extremity or body part. Mentation is not a category within the Glasgow Coma Scale.

PTS: 1 DIF: Apply REF: Table 34-4 Glasgow Coma Scale

7.A client tells the nurse that at first she did not like to exercise but over time has grown to enjoy it and her body lets her know when she has not done enough. The nurse realizes that the client is experiencing which of the following neurological reactions to exercise?

1.

Reduction in serotonin

2.

Reduction in acetylcholine

3.

Increase in endorphins

4.

Reduction in dopamine

ANS: 3

In response to exercise, the body will release endorphins from the pituitary gland, thalamus, spinal cord, and hypothalamus. This neurotransmitter aids to inhibit pain. Exercise does not reduce serotonin, acetylcholine, or dopamine.

PTS: 1 DIF: Analyze REF: Table 34-1 Neurotransmitters: Site and Action

8.Which of the following techniques should the nurse use to assess a clients pupillary response to light?

1.

Briefly shine a penlight into the clients eye by passing the light from the outer edge of the eye toward the center of the eye.

2.

Turn the room lights on and off quickly three times.

3.

Have the client close his eyes and then quickly open them.

4.

Shine the light in the center of the clients eyes for one minute then check them for movement.

ANS: 1

By briefly shining a penlight into the clients eye from the outer edge toward the center of the eye and checking for movement of the pupil, the nurse can tell if there may be brain damage or nerve damage. The other choices are not appropriate technique to assess a clients pupillary response to light.

PTS:1DIF:Apply

REF: CN III: Oculomotor Nerve, CN IV: Trochlear Nerve, and CN VI: Abducens Nerve

9.After assessing a clients plantar reflex, the nurse documents that the finding was normal. Which of the following did the nurse assess in this client?

1.

Extension of the toes

2.

Flexion of the toes

3.

No movement of the toes

4.

Spasming of the toes

ANS: 2

The normal response is flexion of the toes. Any other response could signify neural impairment.

PTS:1DIF:ApplyREF:Reflex Testing

10.A client is scheduled for a computed tomography scan of the brain. Which of the following should the nurse do in order to prepare this client for the diagnosed test?

1.

Shave the clients head.

2.

Administer a sedative.

3.

Check to see if the client is allergic to shellfish or iodine.

4.

Immobilize the head before movement.

ANS: 3

A CT scan commonly uses contrast agents. These contrast agents often have iodine in them. The nurse should check to see if the client is allergic to iodine or shellfish. Shellfish also have iodine in them. The nurse does not need to shave the clients head, administer a sedative, or immobilize the head before movement.

PTS: 1 DIF: Apply REF: Computed Tomography: Nursing Management

11.A client is scheduled for a diagnostic test to assess the amount of electrical activity within each of the cerebral hemispheres. The nurse realizes that the diagnostic test this client will be having is a(n):

1.

myelogram.

2.

electroencephalogram.

3.

transcranial Doppler sonogram.

4.

electromyogram.

ANS: 2

An electroencephalogram or EEG measures the electrical activity of the cerebral hemispheres. A myelogram is an invasive procedure used to visualize obstructions, compression, or herniated intervertebral discs. A transcranial Doppler sonogram measures the velocities of intracranial brain vessels. The electromyogram measures the electrical activity of the peripheral nerves.

PTS: 1 DIF: Analyze REF: Electrographic Studies

12.The nurse is assessing a client recovering from a carotid endarterectomy. Which of the following cranial nerves should the nurse include in this assessment?

1.

CN V

2.

CN VI

3.

CN X

4.

CN XII

ANS: 4

Cranial nerve XII is the hypoglossal nerve. A common cause of dysfunction of this nerve is a carotid endarterectomy. During the surgical procedure, the nerve can be stretched, causing temporary weakness,  the nerve can become severed, causing permanent dysfunction. Cranial nerves V, VI, and X are not affected by a carotid endarterectomy.

PTS: 1 DIF: Apply REF: CN XII: Hypoglossal Nerve

13.The nurse assessed a clients deep tendon reflexes as being normal. Which of the following will the nurse document in the clients medical record?

1.

4+

2.

3+

3.

2+

4.

1+

ANS: 3

A deep tendon reflex of normal would be documented 2+. A deep tendon reflex that is very brisk would be documented as 4+. A deep tendon reflex being more brisk than normal would be documented as 3+. A deep tendon reflex that is sluggish would be documented as 1+.

PTS: 1 DIF: Apply REF: Table 34-7 Deep Tendon Reflex Rating Scale

MULTIPLE RESPONSE

1.During an assessment, the nurse determines that a client is experiencing sympathetic responses. Which of the following did the nurse assess in this client? (Select all that apply.)

1.

Decreased heart rate

2.

Increased bowel sounds

3.

Dilated pupils

4.

Increased heart rate

5.

Increased blood pressure

6.

Increased respiratory rate

ANS: 3, 4, 5, 6

Assessment findings consistent with a sympathetic response include dilated pupils, increased heart rate, increased blood pressure, and increased respiratory rate. Assessment findings consistent with a parasympathetic response include decreased heart rate and increased bowel sounds.

PTS:1DIF:Analyze

REF:Table 34-3 Sympathetic versus Parasympathetic Response

2.The nurse is planning to assess the visual acuity of a client. Which of the following tools can the nurse use to do this assessment? (Select all that apply.)

1.

Snellen chart

2.

Penlight

3.

Cotton wisp

4.

Rosenbaum pocket screener

5.

Sharp object

6.

Newspaper

ANS: 1, 4, 6

Visual acuity can be assessed by using a Snellen chart, the Rosenbaum pocket vision screener, or a newspaper. A penlight is not used to assess visual acuity. A cotton wisp is used to test for a corneal reflex. A sharp object can be used to assess cutaneous reflexes.

PTS:1DIF:ApplyREF:CN II: Optic Nerve

3.A client is assessed as having a taste abnormality. Which of the following terms can the nurse use to describe this assessment finding during documentation? (Select all that apply.)

1.

Diplopia

2.

Ageusia

3.

Hypogeusia

4.

Dysgeusia

5.

Dysphagia

6.

Ataxia

ANS: 2, 3, 4

Taste abnormalities include ageusia, or the absence of the sense of taste; hypogeusia, or diminished taste sensitivity; and dysgeusia, or a disturbed sense of taste. Diplopia is blurred or double vision. Dysphagia is difficulty swallowing. Ataxia is a lack of muscle coordination.

PTS:1DIF:ApplyREF:CN VII: Facial Nerve

4.The nurse determines that a client is experiencing an alteration in sensory functioning when which of the following are assessed? (Select all that apply.)

1.

Anesthesia

2.

Hypesthesia

3.

Parasthesia

4.

Dysesthesia

5.

Hypergesia

6.

Ataxia

ANS: 1, 2, 3, 4, 5

Disorders of sensory functioning can cause a variety of symptoms. Anesthesia is the absence of touch sensation. Hypesthesia is a diminished sense of touch. Parasthesia is numbness, tingling, or prickling sensations. Dysesthesia is burning or tingling. Hypergesia is increased sensitivity to pain. Ataxia described uncoordinated muscle (motor) movements most often assessed during ambulation and is not a part of the assessment of sensory functioning.

PTS:1DIF:AnalyzeREF:Sensory Function

5.The nurse is reviewing the results for a clients analysis of cerebrospinal fluid. Which of the following would be considered an abnormal finding? (Select all that apply.)

1.

Opening pressure 40 mmHg

2.

Cloudy

3.

Elevated red blood cell count

4.

Elevated white blood cell count

5.

Glucose level 60 mg/dL

6.

pH 7.35

ANS: 1, 2, 3, 4

Abnormal cerebrospinal fluid analysis findings include opening pressure 40 mmHg, which could indicate dehydration; cloudy in appearance would indicate an increase in white blood cells; elevated red blood cell count would indicate either a traumatic spinal tap or active bleeding; and elevated white blood cell count would indicate meningitis, tumors, or multiple sclerosis. Glucose level of 60 md/dL is a normal finding. Fluid pH of 7.35 is a normal finding.

PTS: 1 DIF: Analyze REF: Table 34-9 Cerebrospinal Fluid Analysis

Leave a Reply