Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures My Nursing Test Banks

Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. The nurse notes that a patient is not able to voluntary move the right arm. Which part of the brain should the nurse suspect is affected in this patient?
a. Cerebellum
b. Frontal lobe
c. Parietal lobe
d. Hypothalamus
____ 2. A patient is diagnosed with a health problem that alters the way impulses are conducted in the neurological system. When reviewing this information with the patient, which part of a neuron should the nurse teach carries impulses toward the cell body?
a. Axon
b. Dendrite
c. Schwann cell
d. Myelin sheath
____ 3. The nurse is reviewing the vital sign measurements for a patient with a neurological problem. When analyzing these measurements what should the nurse recall as the part of the brain that regulates heart rate and blood pressure?
a. Medulla
b. Cerebrum
c. Cerebellum
d. Hypothalamus
____ 4. The nurse is preparing material about impulse transmission to help with a presentation on the neurological system. When discussing spinal nerves, the nurse will include that each spinal nerve is made up of the dorsal root and which other root?
a. Medial
b. Lateral
c. Ventral
d. Proximal
____ 5. The nurse is explaining the transmission of nerve impulses to a patient with a spinal cord injury. What should the nurse explain as the structure that carries nerve impulses at synapses?
a. Cell membrane
b. Depolarizations
c. Schwanns cells
d. Neurotransmitters
____ 6. A patient learns that abdominal pain is originating from the liver. The nurse should explain to the patient that the impulses from receptors in the internal organs to the central nervous system are transmitted from which type of neurons?
a. Interneurons
b. Efferent neurons
c. Somatic sensory neurons
d. Visceral sensory neurons
____ 7. The nurse is reviewing the results of a patients diagnostic tests which show changes in nerve insulation. What structure should the nurse explain to the patient that electrically insulates neurons?
a. Astrocytes
b. Gray matter
c. Interneurons
d. Myelin sheath
____ 8. The nurse notes that a patient has a history of falling. Which part of the brain should the nurse question as being affected in this patient?
a. Medulla
b. Cerebellum
c. Frontal lobes
d. Hypothalamus
____ 9. The nurse is preparing material about the neurological system as part of major presentation. What should the nurse include that explains the purpose of white matter?
a. Carries either sensory or motor impulses
b. Location of white blood cells within the brain
c. Protects the spinal nerves from potential injury
d. Regulates movement and responses to external stimuli
____ 10. The nurse is caring for an individual with a head injury and notes unequal pupils. Which term should the nurse use to document this finding?
a. Aphasia
b. Nystagmus
c. Anisocoria
d. Ophthalmoplegia
____ 11. The nurse is caring for a patient admitted to the emergency room after a motor vehicle crash. Which assessment is most important for the nurse to complete?
a. Babinski test
b. Romberg test
c. Glasgow Coma Scale
d. Visual analogue scale
____ 12. The nurse is assessing a patients pupils for reactivity to light. Which cranial nerve (CN) is being tested?
a. CN III
b. CN IV
c. CN VI
d. CN XII
____ 13. A neurologist asks a patient to stick out the tongue. Which cranial nerve (CN) is being tested?
a. VII (facial)
b. I (olfactory)
c. IV (trochlear)
d. XII (hypoglossal)
____ 14. A patient reports nearly having a motor vehicle crash and states that his heart was pounding and he was breathing heavy and fast. Currently the patients heart rate and breathing are within normal limits. Which neurotransmitter has resumed control after the patients incident?
a. Serotonin
b. Prostaglandin
c. Acetylcholine
d. Norepinephrine
____ 15. The nurse is caring for a patient diagnosed with a cerebral tumor. For which function should the nurse expect to assess an abnormality?
a. Reflex movement
b. Movement and speech
c. Coordination and posture
d. Heart rate and respiratory rate
____ 16. A 22-year-old female patient recovering from a craniotomy begins crying and asking for her mother who is sleeping in the visitors lounge. The patients Glasgow Coma Scale (GCS) of 15 and pupils are equal and reactive. What nursing action would be most appropriate at this time?
a. Ask the mother to come and stay with the patient.
b. Administer an as-needed sedative to calm the patient.
c. Notify the neurosurgeon that the patient is upset and crying.
d. Reassure the patient, and sit with her until she falls back asleep.
____ 17. The nurse is caring for a patient who has impaired functioning of the left glossopharyngeal (IX) nerve and the vagus (X) nerve. What intervention should the nurse plan to maintain the patients safety while diagnostic testing is being completed?
a. Insert an oral airway.
b. Withhold oral fluid or foods.
c. Obtain a picture board and a Magic Slate.
d. Apply eye patches to keep the eyes closed.
____ 18. The nurse is caring for a patient who is scheduled for a computed tomography (CT) scan of the brain because of new onset of headaches. Which statement by the nurse is most accurate when preparing the patient for the scan?
a. You must shampoo your hair thoroughly tonight to remove oil and dirt.
b. You will need to hold your head completely still during the examination.
c. You may take fluids until about 8 a.m. Then we will give you a special radiopaque drink.
d. We will partially shave your head tonight so that electrodes can be attached securely to your scalp.
____ 19. The nurse is preparing a patient for an electroencephalogram (EEG). What information should be given to the patient?
a. Little needles will be stuck into the scalp.
b. The hair must be clean and dry before the test.
c. The hair at the temporal area will have to be shaved.
d. The patient must withhold fluids and food for 12 hours before the test.
____ 20. The nurse is assisting a neurologist with assessment of a patient with facial muscle weakness. When the neurologist asks the patient to identify different odors, which nerve is being tested?
a. II (optic)
b. X (vagus)
c. I (olfactory)
d. VIII (acoustic)
____ 21. A patient is scheduled for a lumbar puncture. Which action should the nurse take when preparing this patient?
a. Remove all metal jewelry.
b. Administer enemas until clear.
c. Remove the patients dentures.
d. Assist the patient into a side-lying position.
____ 22. The nurse is providing post-procedure care for a patient recovering from a lumbar puncture. Which order should the nurse anticipate for this patient?
a. Keep the patient NPO for 4 hours.
b. Have the patient lie flat for 6 hours.
c. Monitor the patients pedal pulses every 4 hours.
d. Keep the head of the bed elevated 30 degrees for 8 hours.
____ 23. The nurse is caring for a patient who is scheduled for a magnetic resonance imaging (MRI) scan. What explanation should be provided to the patient and family?
a. A scan of the brain will be done after injection of a radioisotope.
b. An MRI uses electrodes placed on the scalp to measure activity of the brain.
c. An MRI measures muscle contraction after stimulation by tiny needle electrodes.
d. An MRI is a noninvasive test that uses magnetic energy to visualize internal parts.
____ 24. A patient who is severely brain damaged has decerebrate posturing with extended extremities. In which area of the brain should the nurse suspect the patient has sustained damage?
a. Cerebrum
b. Brain stem
c. Cerebellum
d. Hypothalamus
____ 25. The nurse is caring for a patient who has had a stroke (brain attack). The patient is unable to understand what the nurse is saying and appears frustrated. What term should the nurse use to document this finding?
a. Dysphagia
b. Confusion
c. Receptive aphasia
d. Expressive aphasia
____ 26. The nurse is assisting as a neurosurgeon examines a patient who has a positive Babinski reflex. What assessment finding should the nurse expect to observe?
a. The leg flexes when the patellar tendon is struck.
b. The leg extends when the patellar tendon is struck.
c. The big toe extends when the sole of the foot is stroked.
d. Toes curl downward when the sole of the foot is stroked.
____ 27. A patient becomes startled when the alarm rings for a fire drill. After reassuring the patient that there is no danger, an assessment is completed. Which finding may be related to a sympathetic response?
a. Wheezing
b. Confusion
c. Incontinence
d. Diminished bowel sounds
____ 28. When the nurse shines a light in a patients left pupil, both of the pupils constrict. What type of response should the nurse document?
a. Direct
b. Abnormal
c. Consensual
d. Accommodation
____ 29. The nurse is providing care for an 87-year-old woman who is recovering from a cerebral vascular accident. Which precaution should the nurse take after noting the patient has a positive Romberg test?
a. Institute fall-risk precautions.
b. Provide small, frequent meals.
c. Request a footboard and splints.
d. Darken the room and reduce stimuli.
____ 30. The nurse is providing care for a client admitted to the hospital after a motor vehicle accident. After being informed by family members that the patient is deaf and mute, which action should the nurse take?
a. Avoid use of the Glasgow Coma Scale.
b. Consider the Babinski response invalid.
c. Utilize a three-point scale to grade muscle strength.
d. Perform the Romberg test with the patient in a seated position.
____ 31. A patient opens the eyes to painful stimuli, makes incomprehensible sounds, and withdraws from pain. What should the nurse calculate this patients Glasgow Coma Scale score to be?
a. 2
b. 4
c. 6
d. 8
____ 32. The nurse suspects that a patient will be diagnosed as being in a comatose state based upon the Glasgow Coma Scale score. What score does the patient need to have to be identified as comatose?
a. 7
b. 9
c. 11
d. 13
____ 33. The nurse is preparing to conduct a Romberg test with a patient. For how many seconds should the nurse explain to the patient that the position will need to be held?
a. 10
b. 20
c. 30
d. 40
____ 34. The nurse is explaining the neurological system to a group of nursing students. How many pairs of spinal nerves should the nurse explain are contained within the human body?
a. 15
b. 25
c. 31
d. 42
____ 35. While collecting data the nurse learns that a patient with a neurological illness has not had a sense of smell for several decades. Which part of the central nervous system should the nurse question as being damaged in this patient?
a. Brainstem
b. Occipital lobe
c. Hypothalamus
d. Temporal lobe
____ 36. The nurse is participating in the preparation of a seminar on the neurologic system for a community health fair. Which part of the system is the nurse referring when the statement rest and digest is included?
a. Left hemisphere of the cerebral cortex
b. Right hemisphere of the cerebral cortex
c. Sympathetic division of the autonomic nervous system
d. Parasympathetic division of the autonomic nervous system
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____ 37. The nurse completes data collection on a newly admitted older patient. Which finding is considered abnormal in an aging patient and should be reported to the physician? (Select all that apply.)
a. Depression
b. Forgetfulness
c. Altered sleep patterns
d. Decreased postural stability
e. Fine motor tremors of the hands
f. Decreased problem-solving ability
____ 38. The nurse is providing care for a patient with a history of aspiration. Which foods should the nurse remove from patients tray? (Select all that apply.)
a. Coffee
b. Ice cream
c. Fruit juice
d. Applesauce
e. Ground chicken
f. Bread with butter
____ 39. The nurse suspects a patient is experiencing a sympathetic response. What manifestations should the nurse expect the patient to demonstrate this response? (Select all that apply.)
a. Relaxation of bladder
b. Decrease in peristalsis
c. Dilation of bronchioles
d. Decrease in heart rate to normal
e. Increase in salivary gland secretion
____ 40. The nurse is caring for a patient scheduled for a computed tomography (CT) scan with contrast. What should be included in pre-procedure preparation? (Select all that apply.)
a. Check blood urea nitrogen (BUN) and creatinine levels.
b. Question the patient about allergies to dye, shellfish, or iodine.
c. Determine if the patient has aneurysm clips or metal pins in the body.
d. Explain to the patient that a sensation of warmth may be felt when dye is injected.
e. Tell the patient to report any nausea, itchiness, or difficulty breathing during the scan.
____ 41. The nurse is preparing a review of the neurological system as part of a community health presentation. Which structures should the nurse identify as being part of the diencephalon? (Select all that apply.)
a. Pons
b. Medulla
c. Thalamus
d. Brainstem
e. Hypothalamus
____ 42. The nurse is caring for a patient scheduled for a lumbar puncture. Which actions should the nurse anticipate providing? (Select all that apply.)
a. Position the patient prone on the bed.
b. Check the puncture site for swelling or drainage.
c. Ensure that the patient has given informed consent to the procedure.
d. Keep the patient on bedrest with the head of the bed flat for 6 hours after the procedure.
e. Limit fluid intake.
f. Assess movement and sensation of lower extremities frequently for several hours after the procedure.
____ 43. While observing the neurologist complete a neurological examination the nurse notes that a patient does not have a left patellar reflex. In which areas should the nurse consider the patient has a dysfunction? (Select all that apply.)
a. Spinal cord
b. Femoral nerve
c. Anterior fibula muscle
d. Posterior tibial muscle
e. Quadriceps femoris muscle
____ 44. A patient is surprised to learn that cerebrospinal fluid will be removed during a lumbar puncture and asks the purpose of the fluid. What should the nurse explain to the patient? (Select all that apply.)
a. Interprets sensory information
b. Provides oxygen to the brain tissue
c. Cushions the central nervous system
d. Conducts electrical impulses between brain hemispheres
e. Exchanges nutrients and wastes between the blood and neurons
____ 45. The nurse is planning to use the FOUR tool to assess a patients neurological functioning. In which areas should the nurse collect data when using this tool? (Select all that apply.)
a. Reflexes
b. Eye response
c. Verbal response
d. Motor movement
e. Breathing pattern

Chapter 47. Neurologic System Function, Assessment, and Therapeutic Measures
Answer Section

MULTIPLE CHOICE

1. ANS: B
The frontal lobes contain the motor areas that generate the impulses that bring about voluntary movement. Each motor area controls movement on the opposite side of the body. C. The parietal lobes contain the general sensory areas for the cutaneous senses, conscious muscle sense (proprioception), and taste (gustation). D. The hypothalamus has varied functions. A. The functions of the cerebellum are concerned with the involuntary aspects of voluntary movement: coordination, the appropriate direction and endpoint of movements, and the maintenance of posture and balance or equilibrium.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

2. ANS: B
A neuron may have one or many dendrites, which are extensions that carry impulses toward the cell body. A. A neuron has one axon that transmits impulses away from the cell body. C. In the peripheral nervous system, axons and dendrites are wrapped in specialized neuroglial cells called Schwann cells. The concentric layers of cell membrane of a Schwann cells plasma membrane form the myelin sheath. D. Myelin is a phospholipid that electrically insulates neurons from one another.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

3. ANS: A
Within the medulla are cardiac centers that regulate heart rate, respiratory centers that regulate breathing, and vasomotor centers that regulate the diameter of blood vessels and therefore blood pressure. B. D. The hypothalamus and cerebrum have varied functions. C. The functions of the cerebellum are concerned with the involuntary aspects of voluntary movement: coordination, the appropriate direction and endpoint of movements, and the maintenance of posture and balance or equilibrium.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

4. ANS: C
Each spinal nerve has two roots, which are neurons entering or leaving the spinal cord. The dorsal root is made of sensory neurons that carry impulses into the spinal cord. The dorsal root ganglion is an enlargement of this root that contains the cell bodies of these sensory neurons. The ventral root is the motor root; it is made of motor neurons that carry impulses from the spinal cord to muscles or glands. (Their cell bodies are in the gray matter of the spinal cord.) When the two roots merge, the nerve thus formed is a mixed nerve. A. B. D. Medial, lateral, and proximal are not parts of a spinal nerve.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

5. ANS: D
The end of the axon is called the synaptic end bulb and contains a chemical neurotransmitter that is released into the synapse by the arrival of the electrical impulse. The neurotransmitter diffuses across the synapse and combines with specific receptor sites on the postsynaptic membrane. At excitatory synapses, the neurotransmitter makes the postsynaptic membrane more permeable to sodium ions, which rush into the cell, initiating an electrical impulse on the membrane of the postsynaptic neuron. A. B. C. Schwann cells, depolarization, and cell membranes are part of the neuron and its function, not the synapse.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

6. ANS: D
Sensory neurons from receptors in internal organs are called visceral sensory neurons. C. Sensory neurons from receptors in the skin, skeletal muscles, and joints are called somatic. B. Motor (efferent) neurons transmit impulses from the central nervous system to effectorsthat is, muscles and glands. A. Interneurons are found entirely within the central nervous system.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

7. ANS: D
Myelin is a phospholipid sheath that electrically insulates neurons from one another. B. C. The gray matter is where the cell bodies of motor neurons and interneurons are located. A. Astrocytes are part of the neuroglia.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

8. ANS: B
The functions of the cerebellum are concerned with the involuntary aspects of voluntary movement: coordination, the appropriate direction and endpoint of movements, and the maintenance of posture and balance or equilibrium. C. The frontal lobes contain the motor areas that generate the impulses that bring about voluntary movement. Each motor area controls movement on the opposite side of the body. The frontal lobes contain the motor areas that generate the impulses that bring about voluntary movement. D. The hypothalamus has many functions. A. The medulla regulates the most vital life functions.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Analysis

9. ANS: A
A nerve tract is a group of thickly myelinated neurons within the central nervous system; such tracts within white matter appear white due to the myelin sheaths. A nerve tract within the spinal cord carries either sensory or motor impulses. B. The white matter does not store white blood cells within the brain. C. The vertebral column protects the spinal nerves from potential injury. D. The white matter does not regulate movement and responses to external stimuli.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

10. ANS: C
Anisocoria describes unequal pupils. A. Aphasia is difficulty speaking or communicating. B. Nystagmus is involuntary movement of the eyes. D. Some patients may be unable to move one or both eyes in a specific direction; this is called ophthalmoplegia.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

11. ANS: C
The Glasgow Coma Scale is an international scale used to assess level of consciousness and document findings and would be the highest priority. D. A visual analog scale is often used to measure pain level. A. B. Babinski and Romberg tests assess muscle function.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

12. ANS: A
CN III controls movement of the eyeball and constriction of the pupil for bright light or near vision. B. C> CN IV and VI control eyeball movement. D. CN XII controls tongue movement.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

13. ANS: D
CN XII controls tongue movement. B. CN I controls sense of smell. C. CN IV is eyeball movement. A. CN VII is taste and facial muscles.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

14. ANS: C
Acetylcholine mediates parasympathetic (peaceful) function. D. Norepinephrine mediates the sympathetic stress response. B. Prostaglandins are involved in pain sensation. A. Serotonin affects mood.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

15. ANS: B
The frontal lobes of the cerebrum contain the motor areas that generate the impulses that bring about voluntary movement. Each motor area controls movement on the opposite side of the body. Also in the frontal lobe, usually only the left lobe is Brocas motor speech area, which controls the movements involved in speaking. D. The medulla controls heart and respiratory rates. C. The cerebellum controls coordination and posture. A. Reflexes are controlled at the spinal cord level.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

16. ANS: A
A GCS of 15 and other assessment findings show the patient is stable. She has been through tremendous stress and wants her mother. D. There is no reason not to ask the mother to come and stay with her. B. A sedative is not indicated and may mask assessment findings. C. There is no reason to contact the surgeon.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Application

17. ANS: B
The patients swallowing and gag reflexes are impaired and could lead to aspiration if food or fluids are given. A. C. D. Cranial nerves (CNs) IX and X do not affect the airway, the eyes, or the ability to communicate.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

18. ANS: B
The patient will need to hold the head still during the test. No special preparation is required for a head CT. A. Shampoo is done before electroencephalogram (EEG). C. Restricting fluids and radiopaque drinks is done prior to gastrointestinal tests. D. Electrodes are for EEGs, but shaving is not necessary.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

19. ANS: B
Evaluation of the electrical activity of the brain is obtained through an EEG. Electrodes are attached to the scalp with an adhesive. Before the test, make sure that the patients hair is clean and dry. C. D. Shaving and fluid restriction are not necessary. A. Needles are not inserted into the scalp for an EEG.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

20. ANS: C
The olfactory nerve controls the sense of smell. A. The optic nerve controls sight. D. The acoustic nerve controls hearing and equilibrium. B. The vagus nerve controls some autonomic functions.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

21. ANS: D
For a lumbar puncture, the nurse assists the patient into a side-lying position with his or her back as close to the edge of the bed nearest the practitioner as possible. Depending on the patients condition, the nurse may need to help the patient flex his or her knees up to the chest. B. Enemas are for gastrointestinal (GI) tests. A. Metal must be removed for magnetic resonance imaging (MRI). D. Dentures are removed for surgeries or endoscopic procedures.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

22. ANS: B
After the lumbar puncture is completed, instruct the patient to remain on bedrest with the head of the bed flat for 6 to 8 hours, as ordered by the physician, and to increase oral intake of fluids. Keeping the head flat decreases the likelihood of leakage of cerebrospinal fluid from the puncture site, which can result in a severe headache. C. Pedal pulses are important for angiograms. A. The patient does not need to be kept at nothing by mouth status for 4 hours. D. Elevating the head of the bed could precipitate a spinal headache.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

23. ANS: D
MRI uses magnetic energy to visualize soft tissues. C describes an electromyogram (EMG). B describes an electroencephalogram (EEG). A is a brain scan.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

24. ANS: B
Abnormal extension posturing, or decerebrate posturing, indicates damage in the area of the brain stem. A. Decorticate posturing indicates significant impairment of cerebral functioning. C. D. There are no specific postures associated with damage to the cerebellum or hypothalamus.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

25. ANS: C
Receptive aphasia affects the patients ability to understand spoken language. D. Expressive aphasia is difficulty or inability to communicate verbally with others. A. Dysphagia is difficulty swallowing. B. A patient who is unable to communicate is not necessarily confused.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Application

26. ANS: C
Babinski reflex is tested by firmly stroking the sole of the foot. If the great toe extends and the other toes fan out, neurological dysfunction should be suspected if the patient is more than 6 months old. D. Normal response is flexion of the great toe. A. B. The Babinski reflex does not assess leg flexion or extension.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

27. ANS: D
The sympathetic division is dominant in stressful situations such as fear, anger, anxiety, and exercise, and the responses it brings about involve preparedness for physical activity, whether or not it is actually needed. The heart rate increases, vasodilation in skeletal muscles supplies them with more oxygen, the bronchioles dilate to take in more air and the liver changes glycogen to glucose to provide energy. Relatively less important activities such as digestion are slowed, and vasoconstriction in the skin and viscera permits greater blood flow to more vital organs such as the brain, heart, and muscles. The urethral sphincter contracts to prevent urination. A. B. C. Wheezing, confusion, and incontinence are not associated with a sympathetic response.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

28. ANS: C
A consensual response means that when one pupil is exposed to direct light, the other pupil also constricts. B. This is a normal response. A. A direct response means the pupil exposed to light constricts. D. Accommodation is the process of visual focusing from far to near.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

29. ANS: A
A positive Romberg test in an older adult is expected as a result of normal aging changes in the cerebellum. Be sure to protect the patient with a positive result from falls. A gait belt may be helpful when assisting the patient with ambulation. B. C. D. The patient does not need a change in meal frequency, a footboard, splints, or a darkened room to reduce stimuli.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

30. ANS: A
A limitation of the Glasgow Coma scale is that if one of the three components cannot be measured, the resulting score is of no use. Because it is not possible to fully evaluate verbal responses for this patient, the scale should not be used. B. The patients inability to hear or speak will not affect the results of a Babinski reflex assessment. C. The patients inability to hear or speak will not affect the scale used to grade muscle strength. D. The Romberg test is not completed in the seated position.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

31. ANS: D
Responds to painful stimuli 2 + makes incomprehensible sounds 2 + withdraws from pain 4 = 8. A. B. C. These are inaccurate calculations of the Glasgow Coma Scale score based upon the patients findings.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

32. ANS: A
A score of less than 7 indicates a comatose patient, and a score of 15 indicates the patient is fully alert and oriented. B. C. D. These scores indicate that the patient has some neurological dysfunction but is not considered comatose.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

33. ANS: B
A negative Romberg test means that the patient experiences minimal swaying for up to 20 seconds. A patient who experiences swaying or who leans to one side is said to have a positive Romberg test. A. The test needs to be conducted for longer than 10 seconds. C. D. The test does not need to be conducted for 30 or 40 seconds.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

34. ANS: C
There are 31 pairs of spinal nerves, named according to their respective vertebrae: 8 cervical pairs, 12 thoracic pairs, 5 lumbar pairs, 5 sacral pairs, and 1 very small coccygeal pair. A. B. There are more than 15 or 25 pairs of spinal nerves. D. There are not 42 pairs of spinal nerves in the body.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

35. ANS: D
Cranial nerve I is the olfactory nerve and originates in the temporal lobe. A. C. Cranial nerves do not originate from the brainstem or hypothalamus. B. Cranial nerve II is the optic nerve and originates in the occipital lobe of the cerebrum.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

36. ANS: D
The parasympathetic division dominates during relaxed, non-stressful situations to promote normal functioning of several organ systems. Digestion proceeds normally, with increased secretions and peristalsis; defecation and urination may occur. C. The sympathetic division is dominant in stressful situations such as fear, anger, anxiety, excitement, and exercise. A. B. The left and right hemispheres of the cerebral cortex would not specifically participate in the resting or digestion processes.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis

MULTIPLE RESPONSE

37. ANS: A, E
With age the brain loses neurons, but this is only a small percentage of the total and is not the usual cause of mental impairment in older adults; far more common causes of mental changes include depression, malnutrition, hypotension, and the side effects of medications. Some forgetfulness is to be expected, however, as is a decreased ability for problem solving, altered sleep patterns, and a decrease in postural stability. Fine motor tremors in the hands are a symptom of Parkinsons disease and are considered an abnormal finding.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

38. ANS: A, C
Patients with swallowing difficulty (dysphagia) may have better success with foods or thick liquids rather than thin fluids. Thin fluids are more easily aspirated and should be altered (thickened) prior to drinking. B. D. E. F. These foods are less likely to cause aspiration.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

39. ANS: A, B, C
When the sympathetic nervous system is activated, the heart rate increases, vasodilation in skeletal muscles supplies them with more oxygen, the bronchioles dilate to take in more air, and the liver changes glycogen to glucose to provide energy. Relatively less important activities such as digestion (and salivation) are slowed, and vasoconstriction in the skin and viscera permits greater blood flow to more vital organs such as the brain, heart, and muscles. The bladder muscle relaxes, and the sphincter constricts to prevent urination.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

40. ANS: A, B, D, E
Patients who are receiving dye should be warned that they may feel a sensation of warmth following the injection; warmth in the groin area may make them feel as though they have been incontinent of urine. Nausea, diaphoresis, itching, or difficulty breathing may indicate allergy to the dye and should be reported immediately to the physician or nurse practitioner. Sedation may be required for patients who are agitated or disoriented. Patients who are in pain may require pain medication before the examination. The patient should be questioned about any allergies to contrast material, iodine, or shellfish. The BUN and creatinine levels should be checked before administration of contrast material because it is excreted through the kidneys. Patients with elevated BUN and creatinine or known renal disease may be unable to tolerate the contrast material. C. Clips or metal pins in the body would be assessed if the patient were scheduled for an MRI.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

41. ANS: E
The diencephalon consists primarily of the thalamus and hypothalamus. D. The diencephalon is superior in structure to the brainstem. A. B. The medulla and pons are structures within the brainstem.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

42. ANS: B, C, D, F
Ensure that informed consent has been obtained prior to the procedure. A. Assist the patient into a side-lying (not prone) position with his or her back as close to the edge of the bed nearest the practitioner as possible. After the lumbar puncture is completed, instruct the patient to remain on bedrest with the head of the bed flat for 6 to 8 hours, as ordered by the physician. E. Oral intake of fluids should be increased. Keeping the head flat decreases the likelihood of leakage of cerebrospinal fluid from the puncture site, which can result in a severe headache. Increasing fluid intake promotes replacement of the fluid that was removed. Check the puncture site for swelling or drainage of cerebrospinal fluid and report any leakage to the health care provider. Assess the movement and sensation to the lower extremities frequently for the first 4 hours after the procedure. Assess the patient for headache, and if necessary, obtain an order for analgesia.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

43. ANS: A, B, E
If the patellar reflex is absent, the problem might be in the quadriceps femoris muscle, the femoral nerve, or the spinal cord itself. C. D. The absence of a patellar reflex does not suggest that a problem exists within the anterior fibula or posterior tibial muscles.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

44. ANS: C, E
Cerebrospinal fluid permits the exchanges of nutrients and wastes between the blood and CNS neurons. It also acts as a cushion or shock absorber for the CNS. A. The cerebrospinal fluid does not interpret sensory information. B. Blood and not cerebrospinal fluid provides oxygen to brain tissue. D. Nerves and not cerebrospinal fluid conduct electrical impulses between the brain hemispheres.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

45. ANS: A, B, D, E
The FOUR tool measures data from four categories: eye response, motor movement, reflexes, and breathing pattern. C. A major benefit of using the FOUR is that no evaluation of verbal response is necessary.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

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