Chapter 56: Nursing Assessment: Nervous System My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 56: Nursing Assessment: Nervous System

Test Bank

MULTIPLE CHOICE

1. When admitting an acutely confused patient with a head injury, which action should the nurse take?

a.

Ask family members about the patients health history.

b.

Ask leading questions to assist in obtaining health data.

c.

Wait until the patient is better oriented to ask questions.

d.

Obtain only the physiologic neurologic assessment data.

ANS: A

When admitting a patient who is likely to be a poor historian, the nurse should obtain health history information from others who have knowledge about the patients health. Waiting until the patient is oriented or obtaining only physiologic data will result in incomplete assessment data; this could adversely affect decision-making about treatment. Asking leading questions may result in inaccurate or incomplete information.

DIF: Cognitive Level: Application REF: 1412-1413

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. A patient has a lesion that affects lower motor neurons. During assessment of the patients lower extremities, the nurse expects to find

a.

spasticity.

b.

flaccidity.

c.

loss of sensation.

d.

hyperactive reflexes.

ANS: B

Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor neuron lesions.

DIF: Cognitive Level: Comprehension REF: 1408-1409

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

3. When performing a focused assessment on a patient with a lesion of the left posterior temporal lobe, the nurse will assess for

a.

sensation on the left side of the body.

b.

voluntary movement on the right side.

c.

reasoning and problem-solving abilities.

d.

understanding of written and oral language.

ANS: D

The posterior temporal lobe integrates the visual and auditory input for language comprehension. Reasoning and problem solving are functions of the anterior frontal lobe. Sensation on the left side of the body is located in the right postcentral gyrus. Voluntary movement on the right side is controlled in the left precentral gyrus.

DIF: Cognitive Level: Application REF: 1409

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

4. Propranolol (Inderal), a -adrenergic blocker that inhibits sympathetic nervous system activity, is prescribed for a patient. The nurse monitors the patient for

a.

dry mouth.

b.

constipation.

c.

slowed pulse.

d.

urinary retention.

ANS: C

Inhibition of the fight or flight response leads to decreased heart rate. Dry mouth, constipation, and urinary retention are associated with peripheral nervous system blockade.

DIF: Cognitive Level: Comprehension REF: 1407 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

5. To assess the functioning of the trigeminal and facial nerves (CN V and VII), the nurse should

a.

apply a cotton wisp strand to the cornea.

b.

have the patient read a magazine or book.

c.

shine a bright light into the patients pupil.

d.

check for unilateral drooping of the eyelids.

ANS: A

The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to check function of the oculomotor nerve.

DIF: Cognitive Level: Comprehension REF: 1416-1417

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

6. Neurologic testing of the patient indicates impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). Which action will the nurse include in the plan of care?

a.

Insert an oral airway.

b.

Withhold oral fluid or foods.

c.

Provide highly seasoned foods.

d.

Apply artificial tears every hour.

ANS: B

The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex; a patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve.

DIF: Cognitive Level: Application REF: 1417 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

7. The following orders are received for an unconscious patient who has just arrived in the emergency department after a head injury caused by an automobile accident. Which one should the nurse question?

a.

Obtain x-rays of the skull and spine.

b.

Prepare the patient for lumbar puncture.

c.

Send for computed tomography (CT) scan.

d.

Perform neurologic checks every 15 minutes.

ANS: B

After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure, which could lead to herniation of the brain with lumbar puncture. The other orders are appropriate.

DIF: Cognitive Level: Application REF: 1418-1419

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

8. A patient is scheduled for a lumbar puncture. The nurse will plan to

a.

transfer the patient to radiology just before the procedure.

b.

help the patient to a side lying position before the procedure.

c.

place the patient on NPO status for 4 hours before the procedure.

d.

administer a sedative medication 30 minutes before the procedure.

ANS: B

For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration.

DIF: Cognitive Level: Application REF: 1418-1419 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

9. During the neurologic assessment, the patient cooperates with the nurses directions to grip with the hands and to move the feet but is unable to respond orally to the nurses questions. The nurse will suspect

a.

a brainstem lesion.

b.

a temporal lobe lesion.

c.

injury to the cerebellum.

d.

damage to the frontal lobe.

ANS: D

Expressive speech is controlled by Brocas area in the frontal lobe. The temporal lobe contains Wernickes area, which is responsible for receptive speech. The cerebellum and brainstem do not affect higher cognitive functions such as speech.

DIF: Cognitive Level: Application REF: 1408-1409

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

10. When developing a plan of care for a patient with dysfunction of the cerebellum, the nurse will include interventions to

a.

prevent falls.

b.

stabilize mood.

c.

enhance swallowing ability.

d.

improve short-term memory.

ANS: A

Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability.

DIF: Cognitive Level: Application REF: 1410 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

11. The nurse notes in the patients medical history that the patient has a positive Romberg test. Which nursing diagnosis is appropriate?

a.

Acute pain related to hyperreflexia and spasm

b.

Risk for falls related to dizziness or weakness

c.

Disturbed tactile sensory perception related to spinal cord damage

d.

Ineffective thermoregulation related to decreased vasomotor response

ANS: B

A positive Romberg test indicates that the patient has difficulty maintaining balance with the eyes closed. The Romberg does not test for tactile perception, thermoregulation, or hyperreflexia.

DIF: Cognitive Level: Application REF: 1417-1418 TOP: Nursing Process: Diagnosis

MSC: NCLEX: Physiological Integrity

12. A patient is hospitalized with a possible seizure disorder. To determine the cause of the patients symptoms, the nurse will anticipate the need to teach the patient about which of these tests?

a.

Cerebral angiography

b.

Evoked potential studies

c.

Electromyography (EMG)

d.

Electroencephalography (EEG)

ANS: D

Seizure disorders are usually studied using EEG testing. Evoked potential is used for diagnosing problems with the visual or auditory systems. Cerebral angiography is used to diagnose vascular problems. EMG is used to evaluate electrical innervation to skeletal muscle.

DIF: Cognitive Level: Comprehension REF: 1419-1423 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

13. When caring for a patient who has had cerebral angiography, which nursing action will be included in the plan of care?

a.

Ask about headache and photophobia.

b.

Keep patient NPO until gag reflex returns.

c.

Check pulse and blood pressure frequently.

d.

Assess orientation to person, place, and time.

ANS: C

Since a catheter is inserted into an artery (such as the femoral artery) during cerebral angiography, the nurse should assess for bleeding after this procedure. The other nursing assessments are not necessary after angiography.

DIF: Cognitive Level: Application REF: 1418-1419 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

14. Which equipment will the nurse obtain to assess vibration sense in a patient who has peripheral nerve dysfunction?

a.

Sharp pin

b.

Tuning fork

c.

Reflex hammer

d.

Calibrated compass

ANS: B

Vibration sense is testing by touching the patient with a vibrating tuning fork. The other equipment is needed for testing of pain sensation, reflexes, and two-point discrimination.

DIF: Cognitive Level: Comprehension REF: 1417-1419

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

15. Which information about a 71-year-old patient is most important for the admitting nurse to report to the patients health care provider?

a.

Triceps reflex response graded at 1/5

b.

Recent unintended weight loss of 20 pounds

c.

Patient complaint of chronic difficulty in falling asleep

d.

Orthostatic drop in systolic blood pressure of 10 mm Hg

ANS: B

Although changes in appetite are normal with aging, a 20-pound weight loss requires further investigation. Orthostatic drops in blood pressure, changes in sleep patterns, and slowing of reflexes are normal changes in aging.

DIF: Cognitive Level: Application REF: 1412-1413 | 1414

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Health Promotion and Maintenance

16. The charge nurse is observing a new staff nurse who is assessing a patient with a possible spinal cord lesion for sensation. Which action indicates a need for further teaching about neurologic assessment?

a.

The new nurse asks the patient, Does this feel sharp?

b.

The new nurse tests for light touch before testing for pain.

c.

The new nurse has the patient close the eyes during testing.

d.

The new nurse uses an irregular pattern to test for intact touch.

ANS: A

When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate.

DIF: Cognitive Level: Application REF: 1417-1418

OBJ: Special Questions: Delegation TOP: Nursing Process: Evaluation

MSC: NCLEX: Safe and Effective Care Environment

17. After reviewing a patients cerebrospinal fluid analysis, which result will be most important for the nurse to communicate to the health care provider?

a.

Specific gravity 1.007

b.

Protein 65 mg/dL (0.30 g/L)

c.

White blood cell (WBC) count 4/L

d.

Glucose 45 mg/dL (1.7 mmol/L)

ANS: D

The protein level is high. The pH, WBCs, and glucose values are normal.

DIF: Cognitive Level: Comprehension REF: 1422

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

18. A patient is scheduled for a myelogram to confirm the presence of a herniated intervertebral disk. Which information obtained when admitting the patient is most important for the nurse to communicate to the health care provider before the procedure?

a.

The patient is anxious about the test.

b.

The patient has an allergy to shellfish.

c.

The patient had 4 ounces of apple juice 4 hours earlier.

d.

The patient has back pain when lying flat for long periods.

ANS: B

Iodine-containing contrast medium is injected into the subarachnoid space during a myelogram. The health care provider may need to modify the postmyelogram orders to prevent back pain, but this can be done after the procedure. Clear liquids are usually considered safe up to 4 hours before a diagnostic or surgical procedure. The patients anxiety should be addressed, but this is not as important as the iodine allergy.

DIF: Cognitive Level: Application REF: 1421-1422

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

19. A patient with a brainstem infarction is admitted to the nursing unit. The priority nursing assessment for the patient is

a.

reflex reaction time.

b.

pupil reaction to light.

c.

level of consciousness.

d.

respiratory rate and rhythm.

ANS: D

Vital centers that control respiration are located in the medulla, and these are the priority assessments because changes in respiratory function may be life threatening. The other information also will be collected by the nurse, but it is not as urgent.

DIF: Cognitive Level: Application REF: 1410

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. Which assessments will the nurse make to test a patients cerebellar function (select all that apply)?

a.

Assess for graphesthesia.

b.

Perform the finger-to-nose test.

c.

Observe arm movement with gait.

d.

Check ability to push against resistance.

e.

Determine ability to sense heat and cold.

ANS: B, C

The cerebellum is responsible for coordination and is assessed by looking at the patients gait and the finger-to-nose test. The other assessments will be used for other parts of the neurological assessment.

DIF: Cognitive Level: Analysis REF: 1417-1418

OBJ: Special Questions: Alternate Item Format

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

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