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Chapter 55: Assessment of Nervous System Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. When admitting an acutely confused patient with a head injury, which action should the nurse

take? Ask family members about the patient’s health history. Ask leading questions to assist in obtaining health data. Wait until the patient is better oriented to ask questions. Obtain only the physiologic neurologic assessment data.

a. b. c. d.

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 patient’s health. Waiting until the patient is oriented or obtaining only physiologic data will result in incomplete assessment data, which could adversely affect decision making about treatment. Asking leading questions may result in inaccurate or incomplete information. DIF: Cognitive Level: Apply (application) REF: 1301 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. Which finding would the nurse expect when assessing the legs of a patient who has a lower

motor neuron lesion? a. Spasticity b. Flaccidity

c. Impaired 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: Understand (comprehension) REF: 1296 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3. The nurse performing a focused assessment of left posterior temporal lobe functions will

assess the patient for sensation on the left side of the body. reasoning and problem-solving ability. ability to understand written and oral language. voluntary movements on the right side of the body.

a. b. c. d.

ANS: C

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: Apply (application) REF: 1298 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

4. Propranolol (Inderal), a b-adrenergic blocker that inhibits sympathetic nervous system

activity, is prescribed for a patient who has extreme anxiety about public speaking. The nurse monitors the patient for a. dry mouth. c. constipation. b. bradycardia. d. urinary retention. ANS: B

Inhibition of the fight-or-flight response leads to a decreased heart rate. Dry mouth, constipation, and urinary retention are associated with peripheral nervous system blockade. DIF: Cognitive Level: Understand (comprehension) REF: 1299 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 5. To assess the functions of the trigeminal and facial nerves (CNs V and VII), the nurse should a. check for unilateral eyelid droop. b. shine a light into the patient’s pupil. c. touch a cotton wisp strand to the cornea. d. have the patient read a magazine or book. ANS: C

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 evaluate function of the oculomotor nerve. DIF: Cognitive Level: Understand (comprehension) REF: 1305 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 6. Which action will the nurse include in the plan of care for a patient with impaired functioning

of the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)? c. Insert an oropharyngeal airway. d. Apply artificial tears every hour.

a. Assist to stand and ambulate. b. Withhold oral fluids and food. 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. Balance and coordination are cerebellar functions. DIF: Cognitive Level: Apply (application) REF: 1305 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 7. An unconscious male patient has just arrived in the emergency department with a head injury

caused by a motorcycle crash. Which order should the nurse question? Obtain x-rays of the skull and spine. Prepare the patient for lumbar puncture. Send for computed tomography (CT) scan. Perform neurologic checks every 15 minutes.

a. b. c. d.

ANS: B

After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure, and herniation of the brain could result if lumbar puncture is performed. The other orders are appropriate. DIF: Cognitive Level: Apply (application) REF: 1310 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 8. A patient with suspected meningitis is scheduled for a lumbar puncture. Before the procedure,

the nurse will plan to enforce NPO status for 4 hours. transfer the patient to radiology. administer a sedative medication. help the patient to a lateral position.

a. b. c. d.

ANS: D

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: Apply (application) REF: 1310 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 9. During the neurologic assessment, the patient is unable to respond verbally to the nurse but

cooperates with the nurse’s directions to move his hands and feet. The nurse will suspect c. frontal lobe damage. d. a temporal lobe lesion.

a. cerebellar injury. b. a brainstem lesion. ANS: C

Expressive speech (ability to express the self in language) is controlled by Broca’s area in the frontal lobe. The temporal lobe contains Wernicke’s area, which is responsible for receptive speech (ability to understand language input). The cerebellum and brainstem do not affect higher cognitive functions such as speech. DIF: Cognitive Level: Apply (application) REF: 1296 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 10. A patient has a tumor in the cerebellum. The nurse will plan interventions to a. prevent falls. c. avoid aspiration. b. stabilize mood. d. improve 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: Apply (application) REF: 1298 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 11. Which problem can the nurse expect for a patient who has a positive Romberg test result? a. Pain c. Aphasia b. Falls d. Confusion ANS: B

A positive Romberg test result indicates that the patient has difficulty maintaining balance when standing with the eyes closed. The Romberg does not test for orientation, thermoregulation, or discomfort. DIF: Cognitive Level: Apply (application) REF: 1307 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 12. The nurse will anticipate teaching a patient with a possible seizure disorder about which test? a. Cerebral angiography c. Electromyography (EMG) b. Evoked potential studies d. Electroencephalography (EEG) ANS: D

Seizure disorders are usually assessed using EEG testing. Evoked potential is used to diagnose 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: Understand (comprehension) REF: 1311 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 13. Which nursing action will be included in the plan of care for a patient who has had cerebral

angiography? Monitor for headache and photophobia. Keep patient NPO until gag reflex returns. Check pulse and blood pressure frequently. Assess orientation to person, place, and time.

a. b. c. d.

ANS: C

Because a catheter is inserted into an artery (e.g., the femoral artery) during cerebral angiography, the nurse should assess for bleeding after this procedure that can affect pulse and blood pressure. The other nursing assessments are not needed after angiography. DIF: Cognitive Level: Apply (application) REF: 1310 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 14. Which equipment will the nurse obtain to assess vibration sense in a patient with diabetes 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: Understand (comprehension) REF: 1307 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 15. Which information about a 76-yr-old patient should the nurse report as uncharacteristic of

normal aging? Triceps reflex response graded at 1/5 Unintended weight loss of 15 pounds 10 mm Hg orthostatic drop in systolic blood pressure Patient complaint of chronic difficulty in falling asleep

a. b. c. d.

ANS: B

Although changes in appetite are normal with aging, a 15-lb 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: Apply (application) REF: 1301 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 traumatic

spinal cord injury for sensation. Which action indicates a need for further teaching of the new nurse about neurologic assessment? a. The new nurse tests for light touch before testing for pain. b. The new nurse has the patient close the eyes during testing. c. The new nurse asks the patient if the instrument feels sharp. d. The new nurse uses an irregular pattern to test for intact touch. ANS: C

When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate. DIF: Cognitive Level: Apply (application) REF: 1306 OBJ: Special Questions: Delegation TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment 17. Which cerebrospinal fluid analysis result should the nurse recognize as abnormal and

communicate to the health care provider? Specific gravity of 1.007 Protein of 65 mg/dL (0.65 g/L) Glucose of 45 mg/dL (1.7 mmol/L) White blood cell (WBC) count of 4 cells/mL

a. b. c. d.

ANS: B

The protein level is high. The specific gravity, WBCs, and glucose values are normal. DIF: Cognitive Level: Understand (comprehension) REF: 1298 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 18. A 39-yr-old patient with a suspected herniated intervertebral disc is scheduled for a

myelogram. Which information communicated by the nurse to the health care provider before the procedure would change the procedural plans? a. The patient is anxious about the test results. b. The patient reports a previous allergy to shellfish. c. The patient has back pain when lying flat for more than 4 hours. d. The patient drank apple juice 4 hours before the scheduled procedure. ANS: B

A contrast medium containing iodine is injected into the subarachnoid space during a myelogram. The patient’s allergy would contraindicate the use of this medium. The health care provider may need to modify the 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 patient’s anxiety should be addressed, but procedural plans would not need to be changed. DIF: Cognitive Level: Apply (application) REF: 1310 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 19. The priority nursing assessment for a patient being admitted with a brainstem infarction is a. pupil reaction. c. reflex reaction time. b. respiratory rate. d. level of consciousness. ANS: B

Vital centers that control respiration are located in the medulla and part of the brainstem, and will require priority assessments because changes in respiratory function may be life threatening. The other information will also be obtained by the nurse but is not as urgent. DIF: Cognitive Level: Apply (application) REF: 1297 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 20. Several patients have been hospitalized for diagnosis of neurologic problems. Which patient

will the nurse assess first? a. A patient with a transient ischemic attack (TIA) returning from carotid duplex

studies b. A patient with a brain tumor who has just arrived on the unit after a cerebral

angiogram c. A patient with a seizure disorder who has just completed an electroencephalogram

(EEG) d. A patient prepared for a lumbar puncture whose health care provider is waiting for

assistance ANS: B

Because cerebral angiograms require insertion of a catheter into the femoral artery, bleeding is a possible complication. The nurse will need to check the pulse, blood pressure, and the catheter insertion site in the groin as soon as the patient arrives. Carotid duplex studies and EEG are noninvasive. The nurse will need to assist with the lumbar puncture as soon as possible, but monitoring for hemorrhage after cerebral angiogram has a higher priority. DIF: Cognitive Level: Analyze (analysis) REF: 1310 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Which assessments will the nurse make to monitor a patient’s cerebellar function (select all

that apply)? a. Test for graphesthesia. b. Observe arm swing with gait.

c. Perform the finger-to-nose test. d. Assess heat and cold sensation. e. Measure strength against resistance. ANS: B, C

The cerebellum is responsible for coordination and is assessed by looking at the patient’s gait and the finger-to-nose test. The other assessments will be used for other parts of the neurologic assessment. DIF: Cognitive Level: Apply (application) REF: 1306 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance...