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Health Assessment for Nursing Practice 6th Edition Wilson Test Bank

Chapter 15: Neurologic System Wilson: Health Assessment for Nursing Practice, 6th Edition MULTIPLE CHOICE 1. A nurse assesses a patient with a head injury who has slowing intellectual functioning,

personality changes, and emotional lability. The nurse correlates these findings with which area of the brain? a. b. Parietal lobe c. Thalamus d. Temporal lobe ANS: A

The frontal lobe controls intellectual function, awareness of self, personality, and autonomic responses related to emotion. The parietal lobe receives sensory input such as position sense, touch, shape, and texture of objects. The thalamus is a relay and integration station from the spinal cord to the cerebral cortex and other parts of the brain. The temporal lobe contains the primary auditory cortex. It also interprets auditory, visual, and somatic sensory inputs that are stored in thought and memory. DIF: Cognitive Level: Understand REF: p. 308 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 2. In assessing a patient with damage to the occipital lobe, the nurse correlates which clinical

manifestation to this injury? a. Intentional tremors b. c. Decreased hearing d. Inability to formulate words ANS: B

The occipital lobe contains the visual cortex. Intentional tremors are caused by cerebellar problems. The temporal lobe contains the auditory cortex. The ability to formulate words comes from the Broca area in the frontal lobe. DIF: Cognitive Level: Understand REF: p. 308 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 3. Which patient behavior indicates to the nurse that the patient’s facial cranial nerve (CN VII) is

intact? a. The patient’s eyes move to the left, right, up, down, and obliquely. b. The patient moistens the lips with the tongue. c. d. The patient’s eyelids blink periodically. ANS: C

Health Assessment for Nursing Practice 6th Edition Wilson Test Bank The finding in option C represents facial symmetry, which is controlled by the facial cranial nerve (CN VII). The finding in option A represents movement of the extraocular muscles, which are controlled by the oculomotor, trochlear, and abducens cranial nerves (CN III, IV, and VI, respectively). The finding in option B represents movement of the tongue, which is controlled by the hypoglossal cranial nerve (CN XII). The finding in option D represents function of the oculomotor cranial nerve (CN III). DIF: Cognitive Level: Apply REF: p. 321 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 4. A nurse assessing a patient who had a cerebrovascular accident involving the Broca area

suspects expressive or nonfluent aphasia. What communication abilities does the nurse anticipate from this patient? a. b. The patient is unable to comprehend speech and thus does not respond verbally. c. The patient is able to understand speech but has difficulty forming words, creating

muffled speech. d. The patient is unable to comprehend speech and responds inappropriately to conversation. ANS: A

The inability to translate ideas into meaningful speech or writing is termed expressive aphasia or nonfluent aphasia and is associated with lesions in the Broca area in the frontal lobe. The inability to comprehend the speech of others is called receptive aphasia or fluent aphasia and is associated with lesions in the Wernicke area in the temporal lobe. Speech pattern A is more consistent with patients who have involvement of muscles of speech rather than neurologic deficits. Speech pattern D is not relevant to this patient. DIF: Cognitive Level: Apply REF: p. 317 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 5. The nurse hears in a report that a patient has receptive or fluent aphasia. What communication

abilities does the nurse anticipate from this patient? a. The patient understands speech but is unable to translate ideas into meaningful

speech. b. The patient is able to understand speech but has difficulty forming words creating

muffled speech. c. d. The patient is emotionally liable and cries easily, which interferes with the ability

to communicate. ANS: C

Health Assessment for Nursing Practice 6th Edition Wilson Test Bank Option C is called receptive aphasia or fluent aphasia and is associated with lesions in the Wernicke area in the temporal lobe. The inability to translate ideas into meaningful speech or writing is termed expressive aphasia or nonfluent aphasia and is associated with lesions in the Broca area in the frontal lobe. Speech pattern B is more consistent with patients who have involvement of muscles of speech rather than neurologic deficits. Speech pattern D is not relevant to this patient. DIF: Cognitive Level: Apply REF: p. 317 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 6. What is the earliest and most sensitive indication of altered cerebral function? a. Unequal pupils b. Loss of deep tendon reflexes c. Paralysis on one side of the body d. ANS: D

Maintaining consciousness represents the functions of and communication between the frontal lobe and reticular activating system. Pupillary function represents function of the oculomotor cranial nerve and the midbrain. Deep tendon reflexes represent function of the spinal cord and reflex arcs. Movement represents function of the spinal cord and posterior frontal lobe. DIF: Cognitive Level: Remember REF: p. 318 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 7. A patient reports having difficulty swallowing. Based on this information, how does the nurse

assess the cranial nerve related to swallowing? a. Ask the patient about feeling the blunt end of a paper clip along the jaw line. b. c. Observe the symmetry of the face when the patient talks. d. Assess taste on the anterior part of the tongue. ANS: B

Option B tests the glossopharyngeal cranial nerve (CN IX), which is involved in swallowing. The nurse must correlate difficulty swallowing with the cranial nerves involved with that function and how to test it. The cranial nerves involved are IX, X, and XII. Option A tests the sensory function of the trigeminal cranial nerve (CN V). Option C tests the motor function of the facial cranial nerve (CN VII). Option D tests the sensory portion of the facial cranial nerve (CN VII). DIF: Cognitive Level: Analyze REF: p. 319 | p. 322 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 8. A patient reports having difficulty swallowing. Based on this information, how does the nurse

assess the appropriate cranial nerve? a.

Health Assessment for Nursing Practice 6th Edition Wilson Test Bank b. Ask the patient to move the head to the right and left. c. Observe the symmetry of the face when the patient talks. d. Assess for taste on the anterior part of the tongue. ANS: A

Option A tests the hypoglossal cranial nerve (CN XII) that is involved in swallowing. The nurse must correlate difficulty swallowing with the cranial nerves involved with that function and how to test them. The cranial nerves involved are IX, X, and XII. Option B tests the function of the spinal accessory cranial nerve (CN XI). Option C tests the motor function of the facial cranial nerve (CN VII). Option D tests the sensory portion of the facial cranial nerve (CN VII). DIF: Cognitive Level: Analyze REF: p. 323 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 9. In assessing a patient’s deep tendon reflexes, a nurse finds a patient has a 4+ triceps response.

How does the nurse interpret this finding? a. b. A diminished response c. An absent response d. An expected response ANS: A

Deep tendon reflexes are graded from 0 to 4+ and 4+ is a hyperactive response. A diminished response is 1+. An absent response is 0. An expected response is 2+. DIF: Cognitive Level: Understand REF: p. 328 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 10. The nurse holds the patient’s relaxed arm with elbow flexed at a 90-degree angle, places a

thumb over a tendon in the antecubital fossa, and strikes the thumb with the pointed end of the reflex hammer. Which deep tendon reflex is the nurse assessing? a. Brachioradialis b c. Triceps d. Deltoid ANS: B

Option B is the correct technique for assessing the biceps deep tendon reflex. The technique described in option A is not the correct one for assessing the brachioradial deep tendon reflex. The technique described in option C is not the correct one for assessing the triceps deep tendon reflex. There is no reflex to test the deltoid muscle. DIF: Cognitive Level: Understand REF: p. 328 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

Health Assessment for Nursing Practice 6th Edition Wilson Test Bank 11. A patient has a compression fracture of the cervical spine at C7 to C8 that is impairing deep

tendon reflexes. Which response will the nurse expect from the affected deep tendon reflex? a. Diminished to absent pronation of the arm b. Diminished to absent flexion of the elbow c. d. Diminished to absent adduction of the upper arm ANS: C

Diminished to absent extension of the elbow is an abnormal response from the triceps deep tendon reflex that is innervated from C6, C7, and C8. Diminished to absent pronation of the arm is an abnormal response from the brachioradial deep tendon reflex that is innervated from C5 to C6. Diminished to absent flexion of the elbow is an abnormal response from the biceps deep tendon reflex that is innervated from C5 to C6. Diminished to absent adduction of the upper arm is not a response of any deep tendon reflex. DIF: Cognitive Level: Analyze REF: p. 328 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 12. A nurse holds the patient’s relaxed left arm, with elbow flexed at a 90-degree angle, in one

hand. The nurse palpates and then strikes the appropriate tendon just above the elbow with either end of the reflex hammer. What is the expected response for this deep tendon reflex? a. Flexion of the left elbow b. Pronation of the left forearm c. Supination of the left arm d. Extension of the left elbow ANS: D

Extension of the left elbow is the normal response of the triceps deep tendon reflex. Flexion of the left elbow would be a normal response for the biceps deep tendon reflex. Pronation of the left forearm would be a normal response for the brachioradialis deep tendon reflex. Supination of the left arm is not a response of any deep tendon reflex. DIF: Cognitive Level: Analyze REF: p. 328 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 13. A nurse holds the patient’s relaxed arm with the elbow flexed at a 90-degree angle, places a

thumb over the appropriate tendon in the antecubital fossa, and strikes the thumb with the pointed end of the reflex hammer. What is the expected response for this deep tendon reflex? a. Extension of the left elbow b. Pronation of the left forearm c. Supination of the left arm d. Flexion of the left elbow ANS: D

Flexion of the left elbow is a normal response for the biceps deep tendon reflex. Pronation of the left forearm is a normal response for the brachioradialis deep tendon reflex. Supination of the left arm is not a response of any deep tendon reflex. Extension of the left elbow is the normal response of the triceps deep tendon reflex.

Health Assessment for Nursing Practice 6th Edition Wilson Test Bank

DIF: Cognitive Level: Analyze REF: p. 328 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 14. How does a nurse test the brachioradial deep tendon reflex? a. Uses the end of the handle on the reflex hammer to stroke the lateral aspect of the

sole of the patient’s foot from heel to ball. b. c. Holds the patient’s relaxed arm with the elbow flexed at a 90-degree angle in one

hand, and palpates and strikes the appropriate tendon just above the elbow with the flat end of the reflex hammer. d. Holds the patient’s relaxed arm with the elbow flexed at a 90-degree angle, places a thumb over the appropriate tendon in the antecubital fossa, and strikes the thumb with the pointed end of the reflex hammer. ANS: B

Option B is the technique to assess the brachioradial deep tendon reflex. Option A is the technique to test plantar flexion, the Babinski reflex. Option C is the technique to test the triceps deep tendon reflex. Option D is the technique to test the biceps deep tendon reflex. DIF: Cognitive Level: Understand REF: p. 328 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 15. A nurse dorsiflexes a patient’s right ankle 90 degrees and then uses a reflex hammer to strike

the appropriate tendon. What is the expected response for this deep tendon reflex? a. Extension of the right lower leg b. Plantar flexion of the right toes c. Dorsiflexion of the right foot d. ANS: D

Plantar flexion is the expected response of the Achilles deep tendon reflex. Extension of the right lower leg is the expected response for the patellar deep tendon reflex. Plantar flexion of the right toes is the expected response for the plantar reflex (Babinski). Dorsiflexion of the right foot is an incorrect response because the nurse is holding the patient’s foot in dorsiflexion, therefore dorsiflexion would not be an expected response. DIF: Cognitive Level: Understand REF: p. 329 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 16. The nurse moves a wisp of cotton lightly across the anterior scalp, paranasal sinuses, and

lower jaw to test the function of which cranial nerve? a. CN IV (trochlear nerve) b c. CN VI (abducens nerve)

Health Assessment for Nursing Practice 6th Edition Wilson Test Bank d. CN VII (facial nerve) ANS: B

The CN V (trigeminal cranial nerve) supplies sensation to the cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, and facial skin. The CN IV (trochlear nerve) supplies downward and inward eye movement. The CN VI (abducens nerve) supplies lateral eye movement. The CN VII (facial nerve) supplies movement of facial expression muscles except the jaw, closes the eyes, and allows labial speech sounds (b, m, w, and rounded vowels). DIF: Cognitive Level: Understand REF: p. 320 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 17. A nurse who is assessing a patient’s eyes finds that the pupils are equal, round, and react to

light and accommodation (PERRLA). These findings verify the expected functioning of which cranial nerve? a. Optic cranial nerve (CN II) b. c. Trochlear cranial nerve (CN IV) d. Abducens cranial nerve (CN VI) ANS: B

The oculomotor cranial nerve (CN III) provides these eye functions. The optic cranial nerve (CN II) provides vision. The trochlear cranial nerve (CN IV) provides eye movement downward and inward. The abducens cranial nerve (CN VI) provides lateral eye movement. DIF: Cognitive Level: Understand REF: p. 319 | p. 320 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 18. In assessing a patient with a tumor in the pons, the nurse expects to find which abnormalities

due to pressure on cranial nerves? a. Dilated pupils and ptosis b. c. Difficulty swallowing d. Impaired gag reflex ANS: B

These abnormalities represent pressure on the facial and acoustic cranial nerves. The nurse correlates the cranial nerves that exit from the pons which are trigeminal (CN V), abducens (CN VI), facial (CN VII), and acoustic (CN VIII). These abnormalities represent pressure on the oculomotor (CN III) that exits from the midbrain. This abnormality represents pressure on the three cranial nerves that affect swallowing: glossopharyngeal (CN IX), vague (CN X), and hypoglossal (CN XII). These cranial nerves exit the brain stem in the medulla oblongata. This reflex is controlled by the vagus cranial nerve (CN IX), which exits the brain stem in the medulla oblongata. DIF: Cognitive Level: Analyze TOP: Nursing Process: Assessment

REF: p. 312

Health Assessment for Nursing Practice 6th Edition Wilson Test Bank MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 19. The nurse assesses the glossopharyngeal nerve (CN IX) by testing which reflex? a. Corneal reflex b. c. Blink reflex d. Cough reflex ANS: B

Movement of the posterior pharynx and gag reflex test is controlled by the glossopharyngeal cranial nerve (CN IX). The corneal reflex is controlled by the trigeminal cranial nerve (CN V). The blink reflex is another name for the corneal reflex. The cough reflex is controlled from the medulla oblongata. DIF: Cognitive Level: Understand REF: p. 312 | p. 322 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 20. Which cranial nerve is assessed when a nurse asks a patient to stick out the tongue and move

it side to side? a. Vagus nerve (CN X) b. Facial nerve (CN VII) c. Abducens nerve (CN VI) d. ANS: D

The hypoglossal cranial nerve provides tongue movement for speech sound articulation (l, t, n) and swallowing. The vagus cranial nerve provides movement for voluntary muscles of phonation (guttural speech sounds) and swallowing. The facial cranial nerve provides movement for facial expression muscles except the jaw, closes the eyes, and allows labial speech sounds (b, m, w, and rounded vowels). The abducens cranial nerve provides for lateral eye movement. DIF: Cognitive Level: Understand REF: p. 323 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 21. As a patient is walking down the hall, the nurse notices the patient’s staggering, unsteady gait.

What findings does the nurse anticipate on the neurologic examination? a. When the patient stands with feet together, eyes open and then closed, an upright

posture is maintained. b. c. When the patient is giving a history to the nurse, a tremor is noticed as the

patient’s hands rest in the lap. d. When lying supine, the patient is able to move the heel of one foot down the shin

of the other leg. ANS: B

Health Assessment for Nursing Practice 6th Edition Wilson Test Bank Patient B has a cerebellar problem as evidenced by the staggering gait (noted at the beginning of the encounter) and the intention tremor on movement (noted during the examination). Option A is a result of a negative Romberg test. This patient has a cerebellar problem, which would result in a positive Romberg test. Option C describes a tremor at rest that occurs in patients with parkinsonism rather than with cerebellar problems. Option D describes a normal response on an examination of cerebellar function. DIF: Cognitive Level: A...