Question 1

When the nurse asks the person to walk heel-to-toe, on toes, then on heels, what function is being checked?&#10;A)Pons.&#10;B)Thalamus.&#10;C)Cerebellar.&#10;D)Medulla oblongata.

Accepted Answer

Walking heel-to-toe, on toes, then on heels is a test of the cerebellar function, which is responsible for coordinating movement and balance. The pons and medulla oblongata are part of the brainstem, responsible for vital functions such as breathing and heart rate. The thalamus is responsible for relaying sensory information to other parts of the brain.

Question 2

A The nurse is caring for a person scheduled for an Electromyogram (EMG). How should the nurse explain this test to the person?&#10;A)It measures cerebral spinal fluid.&#10;B)It measures the skeletal activity of the brain.&#10;C)It measures the electrical activity of the skeletal muscles.&#10;D)It is a diagnostic procedure for aneurysms.

Accepted Answer

An Electromyogram (EMG) measures the electrical activity of the skeletal muscles.

Question 3

When the person is supine and the head is flexed to the chest without pain, resistance, or flexion of the hips or knees, the nurse is observing which neurological sign?&#10;A)Brudzinski's sign.&#10;B)Romberg's sign.&#10;C)Kernig's sign.&#10;D)Babinski's sign.

Accepted Answer

Brudzinski's sign is observed when flexing the head causes involuntary flexion of the hips and knees, indicating meningeal irritation. However, the absence of pain, resistance, or flexion of the hips or knees during this maneuver suggests the absence of Brudzinski's sign, which is a normal finding.

Question 4

The nurse understands that age-related changes in the neurological system include a slower response to change in balance, decreased cerebral blood flow, and decreased metabolism. What is an example of how this would affect home care for an older adult?

A)The older adult will be less able to complete self-care activities.
B)The older adult may need additional time to process information.
C)The older adult will not be open to new learning.
D)The older adult will be easily distracted.

Accepted Answer

The decreased response time and cerebral blood flow can lead to slower processing of information, requiring additional time for the older adult to understand and complete tasks. This may need to be taken into consideration when providing home care for the older adult.

Question 5

A person is brought to the Emergency Department by the rescue squad. The person was thrown from a vehicle. There was questionable consciousness on the way to the hospital. What neurological tests does the nurse expect to see ordered?

A)Magnetic resonance imaging (MRI)and computed tomography (CT).
B)Magnetic resonance imaging (MRI)and positron emission tomography (PET).
C)X-rays of the skull and spine and computed tomography (CT).
D)Computed tomography (CT)and myelogram.

Accepted Answer

X-rays of the skull and spine and CT scan are the most appropriate tests to assess for any fractures, swelling or bleeding in the head and spine. MRI and PET scans are usually not ordered in the acute phase of a head injury, as they are time-consuming and may not be readily available. Myelogram is not usually done in head injury patients.

Question 6

What are abnormal posturings in adults with neurological problems? (Select all that apply.)&#10;A)Decorticate.&#10;B)Dislocate.&#10;C)Decerebrate.&#10;D)Dorsiflexion.

Accepted Answer

Abnormal posturings in adults with neurological problems include decorticate and decerebrate posturing, but not dislocate or dorsiflexion. Decorticate posturing involves the arms being flexed and the legs extended, while decerebrate posturing involves stiff extension of the arms and legs.

Question 7

What is the appearance of normal cerebral spinal fluid (CSF)?&#10;A)Pink without sediment.&#10;B)Clear and colourless.&#10;C)Yellow.&#10;D)Amber.

Accepted Answer

Normal CSF is typically clear and colourless. It should not have any noticeable sediment or discoloration. A pink or yellow appearance may indicate the presence of blood or elevated bilirubin levels respectively, which could indicate a medical condition. Amber-coloured CSF may be a sign of high protein content or inflammation.

Question 8

One of the most common neurological diseases is characterised by abnormal cell firing in the brain. What does this disease cause in persons?&#10;A)Migraines.&#10;B)Decerebrate posturing.&#10;C)Photophobia.&#10;D)Seizures.

Accepted Answer

Abnormal cell firing in the brain is a hallmark of seizures, making option D the correct choice. Migraines can cause severe headaches, nausea and sensitivity to light (photophobia), but they don't typically involve abnormal brain cell firing. Decerebrate posturing is a type of abnormal motor response that may be seen in severe brain injuries, but it is not a disease characterized by abnormal brain cell firing.

Question 9

A person is in the hospital with suspected intracerebral haemorrhage. The nurse realises that the person will most likely have which neurological test ordered?&#10;A)Electroencephalogram (EEG).&#10;B)Computed tomography (CT).&#10;C)Lumbar puncture.&#10;D)X-rays of the skull.

Accepted Answer

A CT scan is the most common diagnostic test used to confirm the presence of an intracerebral hemorrhage. EEGs are used to evaluate brain activity, lumbar punctures check the cerebrospinal fluid, and x-rays of the skull are not reliable for diagnosing intracerebral hemorrhage.

Question 10

What should the nurse ask the person to do when assessing cranial nerve XII?&#10;A)Shrug the shoulders and turn his or her head against resistance.&#10;B) Stick out the tongue and move it from side-to-side.&#10;C)Stand on one foot with his or her eyes closed.&#10;D)Swallow a sip of water.

Accepted Answer

Cranial nerve XII, also called the hypoglossal nerve, is responsible for controlling the movements of the tongue. Therefore, asking the person to stick out their tongue and move it from side-to-side is the appropriate way to assess this nerve.

Question 11

A person in the hospital intensive care unit is being evaluated for brain death. What neurological test helps determine brain death?&#10;A)Cerebral angiogram.&#10;B)Carotid duplex study.&#10;C)Computed tomography (CT).&#10;D)Electroencephalogram (EEG).

Accepted Answer

The answer of A person in the hospital intensive care...

Question 12

The person has lower motor neuron injuries. The nurse realises that what type of reflexes are present?&#10;A)Increased.&#10;B)Intermittent.&#10;C)Decreased.&#10;D)Variable.

Accepted Answer

The answer of The person has lower motor neuron injuries....

Question 13

What should the nurse evaluate when assessing a person's cognitive function?&#10;A)Orientation to time, place, person, and ability to recall recent and past events.&#10;B)Ability to smell items placed under the nose while eyes are closed.&#10;C)Ability to walk with a smooth, steady gait.&#10;D)Pupillary responses.

Accepted Answer

The answer of What should the nurse evaluate when assessing...

Question 14

While performing the Romberg test, the nurse asks the person to stand with the feet together and eyes closed. What must the nurse observe for the test to be considered normal?&#10;A)Swaying rhythmically from side to side.&#10;B)Balance is sufficient to hold still without swaying.&#10;C)Swaying to the affected side and the loss of balance.&#10;D)Minimal swaying for up to 20 seconds.

Accepted Answer

The answer of While performing the Romberg test, the nurse...

Question 15

When the nurse is assessing the functional health pattern of health perception-health management for a person with a neurological problem, which of the following questions is appropriate?&#10;A)'Are you having any problems with the ability to see, hear, taste, or smell?'&#10;B)'Do your health problems interfere with your ability to sleep?'&#10;C)'Do you have any problems with balance, coordination or walking?'&#10;D)'Have you noticed any problems with chewing or swallowing your food?'

Accepted Answer

The answer of When the nurse is assessing the functional...

Question 16

How would the nurse describe Alzheimer's disease to a community group? It: (Select all of the following that apply.)&#10;A)Alzheimer's disease tends to run in families.&#10;B)Alzheimer's disease is caused by a prion.&#10;C)Alzheimer's disease increases in incidence with age.&#10;D)Alzheimer's disease has a short duration.

Accepted Answer

The answer of How would the nurse describe Alzheimer's disease...

Question 17

What does the nurse need to do when assessing a person's muscle strength and movement?&#10;A)Observe to see whether strength and movement are bilaterally equal and strong.&#10;B)Determine evoked potentials.&#10;C)Grade the degree of muscle flaccidity.&#10;D)Ask the person to walk normally in a heel-to-toe sequence.

Accepted Answer

The answer of What does the nurse need to do...

Question 18

When testing a person to determine if tremors are present, what should the nurse assess for?&#10;A)Muscle spasms.&#10;B)Rhythmic movements.&#10;C)Diaphoresis.&#10;D)Jerky movements.

Accepted Answer

The answer of When testing a person to determine if...

Question 19

Normally, a person can differentiate between soft and sharp, and can accurately feel vibrations. What should the nurse do to assess sensory function?&#10;A)Touch both sides of various parts of the person's body with a sharp and a dull object.&#10;B)Have the person distinguish which parts of the body are being touched.&#10;C)Ask the person to state whether he or she is being touched with a paper clip or a needle.&#10;D)Touch a part of the body without the person looking and have them identify the area being touched.

Accepted Answer

The answer of Normally, a person can differentiate between soft...

Question 20

The nurse observes a person who has a lack of coordination, clumsy movements, and an unbalanced gait. What is this called?&#10;A)Dysarthria.&#10;B)Kinaesthesia.&#10;C)Ataxia.&#10;D)Flaccidity.

Accepted Answer

The answer of The nurse observes a person who has...

Deck 40: A Person-Centred Approach to Assessing the Nervous System