LEWIS: Chapter 55: Assessment of Nervous System

1. When admitting an acutely confused 20-year-old patient with a head injury, which action should the nursetake?

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.

a. Ask family members about the patients health history.

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. No sensation

   d. Hyperactive reflexes

b. Flaccidity

3. The nurse performing a focused assessment of left posterior temporal lobe functions will assess the patient for

a. sensation on the left side of the body.

b. voluntary movements on the right side.

c. reasoning and problem-solving abilities.

d. understanding written and oral language.

d. understanding written and oral language.

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.

b. bradycardia.

c. constipation.

d. urinary retention.

b. bradycardia.

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

a. shine a light into the patients pupil.

b. check for unilateral eyelid drooping.

c. touch a cotton wisp strand to the cornea.

d. have the patient read a magazine or book.

a. shine a light into the patients pupil.

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 the vagus nerve (CN X)?

a. Withhold oral fluid or foods.

b. Provide highly seasoned foods.

c. Insert an oropharyngeal airway.

d. Apply artificial tears every hour.

a. Withhold oral fluid or foods.

7. An unconscious male patient has just arrived in the emergency department after a head injury caused by a motorcycle crash. Which order 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.

b. Prepare the patient for lumbar puncture.

8. A patient with suspected meningitis is scheduled for a lumbar puncture. Before the procedure, the nurse will plan to

a. enforce NPO status for 4 hours.

b. transfer the patient to radiology.

c. administer a sedative medication.

d. help the patient to a lateral position

d. help the patient to a lateral position

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

a. cerebellar injury.

b. a brainstem lesion.

c. frontal lobe damage.

d. a temporal lobe lesion.

c. frontal lobe damage.

10. A 45-year-old patient has a dysfunction of the cerebellum. The nurse will plan interventions to

a. prevent falls.

b. stabilize mood.

c. avoid aspiration.

d. improve memory.

a. prevent falls.

11. Which nursing diagnosis is expected to be appropriate for a patient who has a positive Romberg test?

a. Acute pain

b. Risk for falls

c. Acute confusion

d. Ineffective thermoregulation

b. Risk for falls

12. The nurse will anticipate teaching a patient with a possible seizure disorder about which test?

a. Cerebral angiography

b. Evoked potential studies

c. Electromyography (EMG)

d. Electroencephalography (EEG)

d. Electroencephalography (EEG)

13. Which nursing action will be included in the care for a patient who has had cerebral angiography?

a. Monitor for 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.

c. Check pulse and blood pressure frequently.

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

a. Sharp pin

b. Tuning fork

c. Reflex hammer

d. Calibrated compass

b. Tuning fork

15. Which information about a 76-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. Unintended weight loss of 20 pounds

c. 10 mm Hg orthostatic drop in systolic blood pressure

d. Patient complaint of chronic difficulty in falling asleep

b. Unintended weight loss of 20 pounds

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.

c. The new nurse asks the patient if the instrument feels sharp.

17. Which cerebrospinal fluid analysis 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 (0.65 g/L)

c. Glucose 45 mg/dL (1.7 mmol/L)

d. White blood cell (WBC) count 4 cells/mL

b. Protein 65 mg/dL (0.65 g/L)

18. A 39-year-old patient with a suspected herniated intervertebral disc is scheduled for a myelogram. Which information 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 has back pain when lying flat.

d. The patient drank apple juice 4 hours earlier.

b. The patient has an allergy to shellfish.

19. The priority nursing assessment for a 72-year-old patient being admitted with a brainstem infarction is

a. reflex reaction time.

b. pupil reaction to light.

c. level of consciousness.

d. respiratory rate and rhythm.

d. respiratory rate and rhythm.

20. Several patients have been hospitalized for diagnosis of neurologic problems. Which patient will the nurse assess first?

a. Patient with a transient ischemic attack (TIA) returning from carotid duplex studies

b. Patient with a brain tumor who has just arrived on the unit after a cerebral angiogram

c. Patient with a seizure disorder who has just completed an electroencephalogram (EEG)

d. Patient prepared for a lumbar puncture whose health care provider is waiting for assistance

b. Patient with a brain tumor who has just arrived on the unit after a cerebral angiogram

MULTIPLE RESPONSE 1

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

a. Assess for graphesthesia.

b. Observe arm swing with gait.

c. Perform the finger-to-nose test.

d. Check ability to push against resistance.

e. Determine ability to sense heat and cold.

b. Observe arm swing with gait.

c. Perform the finger-to-nose test.

MULTIPLE RESPONSE 2

1. Which nursing actions would be included in the plan of care for a patient after cerebral angiography? (Select all that apply.) a. Monitor for photophobia. 

2. b. Observe for bleeding at the puncture site. 

3. c. Keep patient NPO until gag reflex returns. 

4. d. Check pulse and blood pressure frequently. 

5. e. Assess orientation to person, place, and time. 

ANS: B, D, E 

23. pp Q1

The emergency department nurse is caring for a 78-year old patient whose daughter reports a decrease in cognition. Which nursing statement directed to the patient helps the nurse to assess cognition?

 

1. “Tell me what this fable means to you.”

2. “Please count backward from 100 by 7s.”

3. “Tell me how you were transported to the hospital today.”

4. “I will write a word on this paper, and you copy it.”

1. “Tell me what this fable means to you.

24. pp Q2

The nurse is caring for an older adult who is usually alert and oriented. When the patient exhibits a change in mental status, for which most cause does the nurse initially assess?

1. Infection

2. Use of sedatives

3. Oxygen insufficiency

4. Electrolyte imbalance

1. Oxygen insufficiency

25. pp Q3

The nurse is caring for a 30-year-old patient who experienced a frontal lobe infarction after a motorcycle accident. What is the appropriate nursing intervention?

1. Enable the bed alarm safety system.

2. Place all items directly in front of the patient.

3. Use a picture board to assist with communication.

4. Instruct the patient to use a call light prior to getting out of bed.

a. enable the bed alarm safety system

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