Deck 41: Neurological System

Question 1

When assessing a client's cerebral function,the nurse would evaluate level of consciousness,intellectual function,and which of the following?

A)status of reflexes
B)quality of voice
C)body language
D)pupil reaction

Answer 1

pupil reaction

Question 2

A client's response to assessment of the plantar reflex is to fan the toes and dorsiflect the big toe.The nurse should recognize that this response is indicative of:

A)a normal response
B)stereognosis
C)corticospinal disease
D)a brain tumor

Answer 2

corticospinal disease

Question 3

What type of posturing is characterized by flexion of the arms,adduction of the upper extremities,and extension of the lower extremities resulting from lesions of the cerebral hemispheres or internal structures of the brain?

A)coma
B)extension
C)flexion
D)withdrawal

Answer 3

flexion

Question 4

Which intervention may be used to decrease the intracranial pressure (ICP)of a client who has sustained a head injury?

A)administration of antibiotics
B)administration of corticosteroids and osmotic diuretics
C)passive range of motion every 3 to 4 hours
D)antacids and histamine receptor antagonists

Question 5

What is the lowest possible score indicating deep coma when evaluating a client using the Glasgow Coma Scale?

A)15
B)10
C)3
D)0

Question 6

Which type of skull fracture is of particular concern because of the close proximity of the fragile sinus bones and the adhesion of the dura mater to this area?

A)basilar
B)comminuted
C)depressed
D)linear

Question 7

How should a nurse assess a client's pupillary response to light?

A)Briefly shine a penlight into the client's eye by passing the light from the outer edge of the eye toward the center of the eye.
B)Have the client briefly close his or her eyes and then quickly open them.
C)Have the client turn his or her entire head away from a light source placed on one side of the client.
D)Turn the lights in the room on and off.

Question 8

Which of these communication techniques BEST illustrates how a nurse can assess a client's orientation status?

A)"Tell me what month and day of the week it is."
B)"Did you know you were in the hospital?"
C)"Good morning,Mrs.Smith.I am Nurse Brown.Can you tell me your name?"
D)"My,what a pretty gown.Where did you get it?"

Question 9

A client who is being observed for signs of increasing intracranial pressure (ICP)after a head injury requires suctioning for copious secretions.The nurse must remember which of the following?

A)Nasal suctioning is prohibited for this client.
B)Suction pressure should be limited to 80 to 100 mm H2O for this client.
C)A vagal response may be elicited from suctioning,resulting in an increased ICP.
D)Free-flow oxygen should be provided when suctioning the client.

Question 10

The high content of which substance in cerebrospinal fluid (CSF)can differentiate it from other body fluids?

A)glucose
B)protein
C)salts
D)urea

Question 11

When a nurse is assessing a client's mental status,which observation is pertinent to this exam?

A)assessment of pupil size,equality,roundness,and reaction to light
B)evaluation of both long-term and short-term memory,and memory recall
C)observation of behavior,posture,gestures,and facial expression as compared to expected behaviors of clients of same age,health status,educational level,and social position
D)observation of client's affect as appropriate for the situation

Question 12

Which portion of the peripheral nervous system,activated by stress,prepares the body for the fight-or-flight response?

A)cerebral nervous system
B)parasympathetic nervous system
C)somatic nervous system
D)sympathetic nervous system

Question 13

A client who has been exhibiting flexion posturing after a stroke 2 days ago develops extension posturing.The nurse should recognize that this change indicates the client's condition is:

A)worsening
B)unchanged
C)improving
D)an expected progression of stroke

Question 14

Which of these is the MOST important indicator of a change in the client's neurological status?

A)level of consciousness
B)pupil reaction
C)headaches
D)muscle strength

Question 15

The chemical substance that excites,inhibits,or modifies the response of another neuron is an example of:

A)cerebrospinal fluid (CSF)
B)myelin
C)a neurotransmitter
D)white matter

Question 16

When entering a client's room,a nurse observes the client laughing.The nurse asks what is making the client so happy.The client states angrily,"I'm not happy,you fool! I'm very upset," and then begins to cry.The nurse would note this behavior when evaluating the client's:

A)emotional status
B)intellectual function
C)mental status
D)orientation

Question 17

When assessing a client's coordination,a nurse asks the client to run the heel of one foot down the opposite shin and then repeat with the other heel.The client is unable to do this.What term should the nurse use in recording this assessment?

A)aphasia
B)ataxia
C)posturing
D)symmetry

Question 18

A client is being evaluated every 8 hours using the Glasgow Coma Scale.At 0800 the client's score is 13,and at 1600 the client's score is 10.Which action should the nurse take NEXT?

A)Bring the score to the health care provider's attention during rounds.
B)Call the health care provider now.
C)Chart the score and repeat the evaluation as ordered.
D)Chart the score and repeat the evaluation in 4 hours.

Question 19

Sympathetic and parasympathetic nerves are part of which human nervous system?

A)autonomic
B)central
C)peripheral
D)subnervous

Question 20

A client has an open head injury resulting from a fall and loses consciousness during transport to the hospital.The nurse observes clear fluid in the outer ear,which may indicate:

A)infection in the injured area
B)cerebrospinal fluid leakage
C)injury to facial bones
D)cerebral laceration

Question 21

Which guideline is MOST important for the nurse to teach the client who is at risk for developing a stroke?

A)Decrease intake of caffeinated beverages.
B)Reduce intake of sodium and fat.
C)Monitor weight and activity.
D)Monitor blood-pressure level.

Question 22

Brief episodes of neurological dysfunction caused by temporary impairment of blood flow to the brain that last from a few seconds to 24 hours are called:

A)aneurysms
B)agnosia
C)reversible ischemic neurological deficits
D)transient ischemic attacks

Question 23

A client who has amyotrophic lateral sclerosis (ALS)has a nursing diagnosis of Ineffective breathing patterns related to weakness of respiratory muscles and fatigue.Which goal is appropriate for this diagnosis?

A)Client will experience less fatigue.
B)Client will maintain highest functional ability within limitations of the disease.
C)Client will maintain adequate PaO2 levels.
D)Client will swallow with minimal choking and coughing,and no aspiration.

Question 24

Alzheimer's disease (AD)can be definitively diagnosed by which test?

A)brain biopsy on autopsy
B)brain scan
C)serum acetylcholine level
D)thyroid function

Question 25

Which statement about clients who have primary or metastatic brain tumors is TRUE?

A)Clinical manifestations differ according to the area of the lesion and rate of growth.
B)Classic manifestations include projectile vomiting and headaches.
C)Most tumors are treated by surgical intervention.
D)Most tumors respond to radiation or chemotherapy.

Question 26

Which factor frequently precipitates exacerbations of a client's symptoms of multiple sclerosis?

A)paresthesia
B)blind spots or flashing "lights" in one or both eyes
C)exposure to extreme cold
D)periods of emotional or physical stress

Question 27

Which test is done to identify the causative agent of encephalitis or meningitis?

A)blood culture
B)complete blood count
C)lumbar puncture
D)serum electrolytes

Question 28

Which type of headache is the result of pathological conditions and is caused by compression,inflammation,or hypoxia of pain-sensitive structures?

A)precipitous
B)primary
C)psychosomatic
D)secondary

Question 29

A client who has Parkinson's disease has a nursing diagnosis of Self-care deficit related to immobility,tremors,and bradykinesia.Which nursing intervention is appropriate?

A)Teach the client's family to administer cleansing enemas.
B)Limit client attempts at self-care,since this activity tires the client.
C)Perform personal care activities for the client.
D)Teach the client and family methods to increase the client's ability to perform self-care.

Question 30

For a client who is taking an anticonvulsant,the nurse should instruct the client to:

A)document the progress of any seizures
B)take prescribed medications with orange juice
C)adjust medication dosages according to the amount of seizure activity
D)practice conscientious oral hygiene

Question 31

A nurse is caring for a client who has a spinal cord injury and develops signs of autonomic dysreflexia.Which action should the nurse take immediately?

A)Assess the client's blood pressure every few minutes until within normal limits.
B)Assess the client's respiratory function,and institute intubation procedures,if necessary.
C)Place client flat in bed.
D)Administer client's prescribed analgesic.

Question 32

Clients with a left-sided stroke tend to have which deficit?

A)agnosia
B)aphasia
C)anosognosia
D)unilateral neglect

Question 33

A client tells the nurse about experiencing low back pain that radiates across the buttock and down the leg.The nurse suspects the client has developed a herniated intervertebral disk.Until the diagnosis is confirmed,the nurse should instruct the client to:

A)drink plenty of fluids
B)lie in bed with the knees slightly flexed
C)take over-the-counter analgesics
D)sit in a chair with the legs elevated

Question 34

Characteristically,where does the motor weakness in Guillain-Barré syndrome begin?

A)at the base of the spinal cord where spinal nerves are affected
B)in the arms and progressing down the body
C)in the facial muscles,causing tics and occasionally bizarre contractures
D)in the legs and progressing up the body

Question 35

Which of the following nursing diagnoses would be MOST appropriate for a client with Guillain-Barré syndrome?

A)Ineffective breathing pattern related to loss of respiratory muscle function
B)Risk for injury related to inability to perceive danger in the environment,confusion,impaired judgment,and weakness
C)Pain related to pressure on the brain
D)Altered thought processes related to neuron degeneration and sleep deprivation

Question 36

Which action is recommended for a client diagnosed with Huntington's disease?

A)placing the client in a hospice or long-term care facility
B)encouraging the client to eat frequent,small meals
C)encouraging regular exercise with a family member
D)suggesting genetic counseling for the family

Question 37

What is the primary method of controlling seizures?

A)electric shock therapy
B)pharmacological therapy
C)no primary method
D)surgical intervention

Question 38

For a client who has an embolic stroke,the nurse would place the client in which of these positions?

A)reverse Trendelenburg
B)supine with the bed flat
C)supine with the head of the bed elevated
D)high Fowler's

Question 39

What chronic,progressive hereditary disease of the nervous system is characterized by progressive involuntary choreiform movement and progressive dementia?

A)Alzheimer's disease
B)Huntington's disease
C)multiple sclerosis
D)Parkinson's disease

Question 40

Which nursing action should be included in the care of a client who has viral meningitis?

A)providing frequent small feedings
B)turning the client every 2 hours
C)preparing the client's family for the imminent death of the client
D)providing a quiet environment with minimal stimulation of noise and light

Question 41

The nurse is teaching a client about risk factors for stroke and should include which of the following? (Select all that apply. )

A)does not smoke
B)obesity
C)diabetes
D)cholesterol level of 198
E)blood pressure of 128/80

Question 42

Which neurological movement disorder has prominent behavioral manifestations,including motor tics,repetitive involuntary vocalizations,and copropraxia?

A)Alzheimer's disease
B)Guillain-Barré syndrome
C)Huntington's disease
D)Tourette's syndrome