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TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

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Chapter65:AssessmentofNeurologicFunction  1.

ApatientisbroughttotheERfollowingamotorvehicleaccidentinwhichhesustainedheadtrauma. Preliminaryassessmentrevealsavisiondeficitinthepatientslefteye.Thenurseshouldassociatethis abnormalfindingwithtraumatowhichofthefollowingcerebrallobes?

A)

Temporal

B)

Occipital

C)

Parietal

D)

Frontal

Ans:

B Feedback: Theposteriorlobeofthecerebralhemisphereisresponsibleforvisualinterpretation.Thetemporallobe containstheauditoryreceptiveareas.Theparietallobecontainstheprimarysensorycortex,andis essentialtoanindividualsawarenessofthebodyinspace,aswellasorientationinspaceandspatial relations.Thefrontallobefunctionsinconcentration,abstractthought,informationstorageormemory, andmotorfunction.

2.

Apatientscheduledformagneticresonanceimaging(MRI)hasarrivedattheradiologydepartment.The nursewhopreparesthepatientfortheMRIshouldprioritizewhichofthefollowingactions?

A)

Withholdingstimulants24to48hourspriortoexam

B)

Removingallmetal-containingobjects

C)

InstructingthepatienttovoidpriortotheMRI

D)

InitiatinganIVlineforadministrationofcontrast

Ans:

B Feedback: PatientpreparationforanMRIconsistsofremovingallmetal-containingobjectspriortothe examination.WithholdingstimulantswouldnotaffectanMRI;thisrelatestoanelectroencephalography (EEG).Instructingthepatienttovoidispatientpreparationforalumbarpuncture.InitiatinganIVline foradministrationofcontrastwouldbedoneifthepatientwashavingaCTscanwithcontrast.

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

3.

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Agerontologicnurseplanningtheneurologicassessmentofanolderadultisconsideringnormal,agerelatedchanges.Ofwhatphenomenonshouldthenursebeaware?

A)

Hyperactivedeeptendonreflexes

B)

Reductionincerebralbloodflow

C)

Increasedcerebralmetabolism

D)

Hypersensitivitytopainfulstimuli

Ans:

B Feedback: Reductionincerebralbloodflow(CBF)isachangethatoccursinthenormalagingprocess.Deep tendonreflexescanbedecreasedor,insomecases,absent.Cerebralmetabolismdecreasesasthepatient advancesinage.Reactiontopainfulstimulimaybedecreasedwithage.Becausepainisanimportant warningsignal,cautionmustbeusedwhenhotorcoldpacksareused.

4.

Thenursehasadmittedanewpatienttotheunit.Oneofthepatientsadmittingordersisforan adrenergicmedication.Thenurseknowsthatthismedicationwillhavewhateffectonthecirculatory system?

A)

Thin,waterysaliva

B)

Increasedheartrate

C)

DecreasedBP

D)

Constrictedbronchioles

Ans:

B Feedback: Thetermadrenergicreferstothesympatheticnervoussystem.Sympatheticeffectsincludeanincreased rateandforceoftheheartbeat.Cholinergiceffects,whichcorrespondtotheparasympatheticdivisionof theautonomicnervoussystem,includethin,waterysaliva,decreasedrateandforceofheartbeat,and decreasedBP.

5.

A)

Anurseisassessingreflexesinapatientwithhyperactivereflexes.Whenthepatientsfootisabruptly dorsiflexed,itcontinuestobeattwotothreetimesbeforesettlingintoarestingposition.Howwouldthe nursedocumentthisfinding? Rigidity

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

B)

Flaccidity

C)

Clonus

D)

Ataxia

Ans:

C

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Feedback: Whenreflexesareveryhyperactive,aphenomenoncalledclonusmaybeelicited.Ifthefootisabruptly dorsiflexed,itmaycontinuetobeattwotothreetimesbeforeitsettlesintoapositionofrest.Rigidityis anincreaseinmuscletoneatrestcharacterizedbyincreasedresistancetopassivestretch.Flaccidityis lackofmuscletone.Ataxiaistheinabilitytocoordinatemusclemovements,resultingindifficulty walking,talking,andperformingself-careactivities. 6.

Thenurseisdoinganinitialassessmentonapatientnewlyadmittedtotheunitwithadiagnosisof cerebrovascularaccident(CVA).Thepatienthasdifficultycopyingafigurethatthenursehasdrawnand isdiagnosedwithvisual-receptiveaphasia.Whatbrainregionisprimarilyinvolvedinthisdeficit?

A)

Temporallobe

B)

Parietal-occipitalarea

C)

Inferiorposteriorfrontalareas

D)

Posteriorfrontalarea

Ans:

B Feedback: Difficultycopyingafigurethatthenursehasdrawnwouldbeconsideredvisual-receptiveaphasia, whichinvolvestheparietal-occipitalarea.Expressiveaphasia,theinabilitytoexpressoneself,isoften associatedwithdamagetothefrontalarea.Receptiveaphasia,theinabilitytounderstandwhatsomeone elseissaying,isoftenassociatedwithdamagetothetemporallobearea.

7.

Whattermisusedtodescribethefibrousconnectivetissuethathugsthebraincloselyandextendsinto everyfoldofthebrainssurface?

A)

Duramater

B)

Arachnoid

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

C)

Fascia

D)

Piamater

Ans:

D

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Feedback: Thetermmeningesdescribesthefibrousconnectivetissuethatcoversthebrainandspinalcord.The meningeshavethreelayers,theduramater,arachnoid,andpiamater.Thepiamateristheinnermost membranethathugsthebraincloselyandextendsintoeveryfoldofthebrainssurface.Theduramater, theoutermostlayer,coversthebrainandspinalcord.Thearachnoid,themiddlemembrane,is responsiblefortheproductionofcerebrospinalfluid. 8.

Thenurseiscaringforapatientwithanuppermotorneuronlesion.Whatclinicalmanifestationsshould thenurseanticipatewhenplanningthepatientsneurologicassessment?

A)

Decreasedmuscletone

B)

Flaccidparalysis

C)

Lossofvoluntarycontrolofmovement

D)

Slowreflexes

Ans:

C Feedback: Uppermotorneuronlesionsdonotcausemuscleatrophy,flaccidparalysis,orslowreflexes.However, uppermotorneuronlesionsnormallycauselossofvoluntarycontrol.

9.

Thenurseisadmittingapatienttotheunitwhoisdiagnosedwithalowermotorneuronlesion.What entryinthepatientselectronicrecordismostconsistentwiththisdiagnosis?

A)

Patientexhibitsincreasedmuscletone.

B)

Patientdemonstratesnormalmusclestructurewithnoevidenceofatrophy.

C)

Patientdemonstrateshyperactivedeeptendonreflexes.

D)

Patientdemonstratesanabsenceofdeeptendonreflexes.

Ans:

D

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

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Feedback: Lowermotorneuronlesionscauseflaccidmuscleparalysis,muscleatrophy,decreasedmuscletone,and lossofvoluntarycontrol. 10. Anelderlypatientisbeingdischargedhome.Thepatientlivesaloneandhasatrophyofhisolfactory organs.Thenursetellsthepatientsfamilythatitisessentialthatthepatienthavewhatinstalledinthe home? A)

Grabbars

B)

Nonslipmats

C)

Baseboardheaters

D)

Asmokedetector

Ans:

D Feedback: Thesenseofsmelldeteriorateswithage.Theolfactoryorgansareresponsibleforsmell.Thismay presentasafetyhazardforthepatientbecauseheorshemaynotsmellsmokeorgasleaks.Smoke detectorsareuniversallynecessary,butespeciallyforthispatient.

11. ThepatientintheEDhasjusthadadiagnosticlumbarpuncture.Toreducetheincidenceofapostlumbarpunctureheadache,whatisthenursesmostappropriateaction? A)

Positionthepatientprone.

B)

Positionthepatientsupinewiththeheadofbedflat.

C)

Positionthepatientleftside-lying.

D)

Administeracetaminophenasordered.

Ans:

A Feedback: Thelumbarpunctureheadachemaybeavoidedifasmall-gaugeneedleisusedandifthepatientremains proneaftertheprocedure.Acetaminophenisnotadministeredasapreventativemeasureforpost-lumbar punctureheadaches.

12. Thenurseisconductingafocusedneurologicassessment.Whenassessingthepatientscranialnerve

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

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function,thenursewouldincludewhichofthefollowingassessments? A)

Assessmentofhandgrip

B)

Assessmentoforientationtoperson,time,andplace

C)

Assessmentofarmdrift

D)

Assessmentofgagreflex

Ans:

D Feedback: Thegagreflexisgovernedbytheglossopharyngealnerve,oneofthecranialnerves.Handgripandarm driftingarepartofmotorfunctionassessment.Orientationisanassessmentparameterrelatedtoamental statusexamination.

13. AnurseiscaringforapatientdiagnosedwithMniresdisease.Whilecompletinganeurologic examinationonthepatient,thenurseassessescranialnerveVIII.Thenursewouldbecorrectin identifyingthefunctionofthisnerveaswhat? A)

Movementofthetongue

B)

Visualacuity

C)

Senseofsmell

D)

Hearingandequilibrium

Ans:

D Feedback: CranialnerveVIII(acoustic)isresponsibleforhearingandequilibrium.CranialnerveXII(hypoglossal) isresponsibleformovementofthetongue.CranialnerveII(optic)isresponsibleforvisualacuityand visualfields.CranialnerveI(olfactory)functionsinsenseofsmell.

14. Apatientexhibitinganuncoordinatedgaithaspresentedattheclinic.Whichofthefollowingisthemost plausiblecauseofthispatientshealthproblem? A)

Cerebellardysfunction

B)

Alesioninthepons

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

C)

Dysfunctionofthemedulla

D)

Ahemorrhageinthemidbrain

Ans:

A

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Feedback: Thecerebellumcontrolsfinemovement,balance,positionsense,andintegrationofsensoryinput. Portionsoftheponscontroltheheart,respiration,andbloodpressure.CranialnervesIXthroughXII connecttothebraininthemedulla.CranialnervesIIIandIVoriginateinthemidbrain. 15. ThenursingstudentsarelearninghowtoassessfunctionofcranialnerveVIII.Toassessthefunctionof cranialnerveVIIIthestudentswouldbecorrectincompletingwhichofthefollowingassessment techniques? A)

Havethepatientidentifyfamiliarodorswiththeeyesclosed.

B)

Assesspapillaryreflex.

C)

UtilizetheSnellenchart.

D)

Testforairandboneconduction(Rinnetest).

Ans:

D Feedback: CranialnerveVIIIistheacousticnerve.Itfunctionsinhearingandequilibrium.Whenassessingthis nerve,thenursewouldtestforairandboneconduction(Rinne)withatuningfork.Assessmentof papillaryreflexwouldbecompletedforcranialnervesIII(oculomotor),IV(trochlear),andVI (abducens).TheSnellenchartwouldbeusedtoassesscranialnerveII(optic).

16. Apatientisbeinggivenamedicationthatstimulatesherparasympatheticsystem.Following administrationofthismedication,thenurseshouldanticipatewhateffect? A)

Constrictedpupils

B)

Dilatedbronchioles

C)

Decreasedperistalticmovement

D)

Relaxedmuscularwallsoftheurinarybladder

Ans:

A

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

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Feedback: Parasympatheticstimulationresultsinconstrictedpupils,constrictedbronchioles,increasedperistaltic movement,andcontractedmuscularwallsoftheurinarybladder. 17. Apatientwithlowerbackpainisscheduledformyelographyusingmetrizamide(awater-soluble contrastdye).Afterthetest,thenurseshouldprioritizewhataction? A)

Positioningthepatientwiththeheadofthebedelevated45degrees

B)

AdministeringIVmorphinesulfatetopreventheadache

C)

Limitingfluidsforthenext12hours

D)

Helpingthepatientperformdeepbreathingandcoughingexercises

Ans:

A Feedback: Aftermyelography,thepatientliesinbedwiththeheadofthebedelevated30to45degrees.Thepatient isadvisedtoremaininbedintherecommendedpositionfor3hoursorasprescribed.Drinkingliberal amountsoffluidforrehydrationandreplacementofCSFmaydecreasetheincidenceofpostlumbar punctureheadache.Deepbreathingandcoughingexercisesarenotnormallynecessarysincethereisno consequentriskofatelectasis.

18. Apatientishavingafightorflightresponseafterreceivingbadnewsabouthisprognosis.Whataffect willthishaveonthepatientssympatheticnervoussystem? A)

Constrictionofbloodvesselsintheheartmuscle

B)

Constrictionofbronchioles

C)

Increaseinthesecretionofsweat

D)

Constrictionofpupils

Ans:

C Feedback: Sympatheticnervoussystemstimulationresultsindilatedbloodvesselsintheheartandskeletalmuscle, dilatedbronchioles,increasedsecretionofsweat,anddilatedpupils.

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

1231

19. Thenurseeducatorisreviewingtheassessmentofcranialnerves.Whatshouldtheeducatoridentifyas thespecificinstanceswhencranialnervesshouldbeassessed?Selectallthatapply. A)

Whenaneurogenicbladderdevelops

B)

Whenlevelofconsciousnessisdecreased

C)

Withbrainstempathology

D)

Inthepresenceofperipheralnervoussystemdisease

E)

Whenaspinalreflexisinterrupted

Ans:

B,C,D Feedback: Cranialnervesareassessedwhenlevelofconsciousnessisdecreased,withbrainstempathology,orin thepresenceofperipheralnervoussystemdisease.Abnormalitiesinmuscletoneandinvoluntary movementsarelesslikelytoprompttheassessmentofcranialnerves,sincethesenervesdonotdirectly mediatemostaspectsofmuscletoneandmovement.

20. ApatientintheORgoesintomalignanthyperthermiaduetoanabnormalreactiontotheanesthetic.The nurseknowsthattheareaofthebrainthatregulatesbodytemperatureiswhichofthefollowing? A)

Cerebellum

B)

Thalamus

C)

Hypothalamus

D)

Midbrain

Ans:

C Feedback: Thehypothalamusplaysanimportantroleintheendocrinesystembecauseitregulatesthepituitary secretionofhormonesthatinfluencemetabolism,reproduction,stressresponse,andurineproduction.It workswiththepituitarytomaintainfluidbalancethroughhormonalreleaseandmaintainstemperature regulationbypromotingvasoconstrictionorvasodilatation.Thecerebellum,thalamus,andmidbrainand notdirectlyinvolvedintemperatureregulation.

21. ThenurseisplanningthecareofapatientwithParkinsonsdisease.Thenurseshouldbeawarethat treatmentwillfocusonwhatpathophysiologicalphenomenon?

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

A)

Prematuredegradationofacetylcholine

B)

Decreasedavailabilityofdopamine

C)

Insufficientsynthesisofepinephrine

D)

Delayedreuptakeofserotonin

Ans:

B

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Feedback: Parkinsonsdiseasedevelopsfromdecreasedavailabilityofdopamine,notacetylcholine,epinephrine,or serotonin. 22. Apatientisadmittedtothemedicalunitwithanexacerbationofmultiplesclerosis.Whenassessingthis patient,thenursehasthepatientstickouthertongueandmoveitbackandforth.Whatisthenurse assessing? A)

Functionofthehypoglossalnerve

B)

Functionofthevagusnerve

C)

Functionofthespinalnerve

D)

Functionofthetrochlearnerve

Ans:

A Feedback: Thehypoglossalnerveisthe12thcranialnerve.Itisresponsibleformovementofthetongue.Noneof theotherlistednervesaffectsmotorfunctioninthetongue.

23. AtraumapatientwasadmittedtotheICUwithabraininjury.Thepatienthadachangeinlevelof consciousness,increasedvitalsigns,andbecamediaphoreticandagitated.Thenurseshouldrecognize whichofthefollowingsyndromesasthemostplausiblecauseofthesesymptoms? A)

Adrenalcrisis

B)

Hypothalamiccollapse

C)

Sympatheticstorm

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

D)

Cranialnervedeficit

Ans:

C

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Feedback: Sympatheticstormisasyndromeassociatedwithchangesinlevelofconsciousness,alteredvitalsigns, diaphoresis,andagitationthatmayresultfromhypothalamicstimulationofthesympatheticnervous systemfollowingtraumaticbraininjury.Alterationsincranialnerveoradrenalfunctionwouldnothave thisresult. 24. Assessmentiscrucialtothecareofpatientswithneurologicdysfunction.Whatdoesaccurateand appropriateassessmentrequire?Selectallthatapply. A)

Theabilitytoselectmediationsfortheneurologicdysfunction

B)

Understandingofthetestsusedtodiagnoseneurologicdisorders

C)

Knowledgeofnursinginterventionsrelatedtoassessmentanddiagnostictesting

D)

Knowledgeoftheanatomyofthenervoussystem

E)

Theabilitytointerprettheresultsofdiagnostictests

Ans:

B,C,D Feedback: Assessmentrequiresknowledgeoftheanatomyandphysiologyofthenervoussystemandan understandingofthearrayoftestsandproceduresusedtodiagnos...