Question 1

The nurse is planning to assess a patient's brachioradialis reflex. Place an "X" on the picture that represents the technique the nurse will use to test this reflex.

Accepted Answer

The answer of The nurse is planning to assess a...

Question 2

The nurse reads that a patient's reflexes are 3+. How should the nurse interpret this finding?

Accepted Answer

A reflex grade of 3+ indicates that the patient's reflexes are stronger than normal. Normal reflexes are typically graded as 2+. A reflex grade of 1+ or 0 indicates weaker than normal reflexes, while a reflex grade of 4+ or higher indicates hyperactive reflexes.

Question 3

The nurse is assessing the patient using the technique shown. Which finding should the nurse consider normal?

Accepted Answer

The normal finding during this assessment would be no pain or resistance in either hip or knee joint. Therefore, option D is the correct choice. Option A indicates pain during flexion which is not normal. Option B indicates resistance in the hip joint which is not normal. Option C indicates a clicking sound in the knee upon flexion which is not necessarily normal.

Question 4

A patient reports hearing noises when alone in a quiet room. What action should the nurse take?

Accepted Answer

The nurse should assess further by asking if the patient experiences any visual disturbances, as this could provide more information about the patient's condition and help determine the appropriate course of action.

Question 5

During an assessment of a patient's cranial nerves, the nurse states, "Please stick out your tongue." The nurse observes that the tongue deviates markedly to the right side. What is the patient most likely exhibiting?

Accepted Answer

The deviation of the tongue to one side indicates dysfunction of the hypoglossal nerve (CN XII), as this nerve controls the movement of the tongue.

Question 6

The meal tray for a patient with damage to the glossopharyngeal nerve (CN IX) has been delivered. What action should the nurse take first?

Accepted Answer

Assessing the patient's ability to swallow is the priority because damage to the glossopharyngeal nerve (CN IX) can affect the muscles involved in swallowing and increase the risk of aspiration. Knowing what is on the tray, making eye contact, and assisting with identifying items on the tray may be important but are secondary to ensuring the patient can safely swallow.

Question 7

The nurse is preparing to conduct an assessment of a patient's neurological status. What is the nurse assessing for in this diagram?

Accepted Answer

The answer of The nurse is preparing to conduct an...

Question 8

The nurse asks a patient who has suffered a cerebral vascular accident (CVA) to complete the heel-to-shin test. What is the nurse testing for with this technique?

Accepted Answer

The heel-to-shin test is used to assess the patient's coordination. The nurse would have the patient place the heel of one foot on the opposite knee and run the heel down the shin to the ankle. If the patient is able to do this smoothly and accurately, it indicates good coordination. If the patient has difficulty or performs the action awkwardly, it may suggest ataxia, a lack of muscle coordination.

Question 9

The patient sustained a head injury in a fall and now is having problems seeing. Place an X on the area of the brain where the nurse suspects this patient has been injured.

Accepted Answer

The answer of The patient sustained a head injury in...

Question 10

The nurse is caring for a patient with lesions in the corticospinal tracts. Place an "X" on the position that the nurse should expect to assess in this patient?

Accepted Answer

The answer of The nurse is caring for a patient...

Question 11

The nurse is reviewing the part of the nervous system that controls cardiac rate, blood pressure, respiration, and swallowing with the family of a patient with a stroke. Which structure should the nurse identify as controlling these functions?

Accepted Answer

The answer of The nurse is reviewing the part of...

Question 12

The nurse observes signs that a patient may be experiencing dysfunction related to the acoustic nerve (CN VIII). Which actions should the nurse take to minimize the patient's risk for injury?

Accepted Answer

The acoustic nerve (CN VIII) is related to hearing and balance. Identifying the patient's fall risk category (A), assisting with sitting or toileting (C), and placing a "falls risk" bracelet (E) are appropriate actions to minimize injury risk due to balance issues.

Question 13

An emergency department (ED) nurse receives a report that an incoming patient has a Glasgow Coma Scale (GCS) score of 8. Which is the most appropriate action by the nurse?

Accepted Answer

A GCS score of 8 indicates a severe impairment of consciousness, so the first priority of the nurse should be to ensure the patient's airway, breathing, and circulation are stable. Once these vital signs have been assessed and treated as necessary, the nurse can move on to other priorities such as pain management and obtaining a history. Triage should not be the nurse's initial priority.

Question 14

The nurse is conducting a health history with a patient exhibiting signs of Parkinson disease. Which question should the nurse ask the patient?

Accepted Answer

Parkinson's disease can have a genetic component, so asking about a family history of similar symptoms can be helpful in diagnosis. Choice B is not relevant to Parkinson's disease. Choice C is more relevant to meningitis. Choice D may be relevant but is not as specific to Parkinson's disease as asking about a family history.

Question 15

The nurse is conducting a neurological assessment of a patient. Place an "X" on the technique the nurse should use to test for graphesthesia.

Accepted Answer

The answer of The nurse is conducting a neurological assessment...

Question 16

During a health assessment interview, the nurse notices the patient has a fine tremor in the right hand and arm. The patient says, "They tell me this is a primary essential tremor. What does that mean?" What is the best response by the nurse?

Accepted Answer

Essential tremor is a neurological disorder that causes involuntary shaking movements, usually in the arms and hands. When it is a primary disorder, it is usually inherited, meaning it runs in families. It is not necessarily an indication of Parkinson's disease or cardiovascular disease, although some people with essential tremor may also have other health conditions. A fine tremor is a common symptom of essential tremor.

Question 17

During a health history the nurse plans to assess the functioning of a patient's central nervous system (CNS). Which question should the nurse ask to assess this function?

Accepted Answer

The answer of During a health history the nurse plans...

Question 18

A patient experiencing extreme emotional stress is observed to be exhibiting both tachycardia and tachypnea. Which component of the patient's nervous system is responsible for normalizing the patient's response?

Accepted Answer

The parasympathetic nervous system is responsible for normalizing physiological responses during periods of stress. It slows down tachycardia and tachypnea, bringing the body back to a state of homeostasis.

Question 19

A patient is prescribed a medication that affects the beta₁- and beta₂-receptors in the body. Which effects of this medication should the nurse expect to assess?

Accepted Answer

The answer of A patient is prescribed a medication that...

Question 20

A patient is brought to the emergency department following a motor vehicle accident. The patient jerks away from the nurse attempting to start an IV in the right arm and says, "Bring me my book. I need to eat." When asked what happened in the accident, the patient looks frantically from nurse to nurse and says, "I have a dog." Calculate the patient's Glasgow Coma score.  Record your answer rounding to the nearest whole number.

Accepted Answer

The answer of A patient is brought to the emergency...

Quiz 41: Assessing the Nervous System

The nurse is planning to assess a patient's brachioradialis reflex. Place an "X" on the picture that represents the technique the nurse will use to test this reflex.

The nurse reads that a patient's reflexes are 3+. How should the nurse interpret this finding?

The nurse is assessing the patient using the technique shown. Which finding should the nurse consider normal?

A patient reports hearing noises when alone in a quiet room. What action should the nurse take?

During an assessment of a patient's cranial nerves, the nurse states, "Please stick out your tongue." The nurse observes that the tongue deviates markedly to the right side. What is the patient most likely exhibiting?

The meal tray for a patient with damage to the glossopharyngeal nerve (CN IX) has been delivered. What action should the nurse take first?

The nurse is preparing to conduct an assessment of a patient's neurological status. What is the nurse assessing for in this diagram?

The nurse asks a patient who has suffered a cerebral vascular accident (CVA) to complete the heel-to-shin test. What is the nurse testing for with this technique?

The patient sustained a head injury in a fall and now is having problems seeing. Place an X on the area of the brain where the nurse suspects this patient has been injured.

The nurse is caring for a patient with lesions in the corticospinal tracts. Place an "X" on the position that the nurse should expect to assess in this patient?

The nurse is reviewing the part of the nervous system that controls cardiac rate, blood pressure, respiration, and swallowing with the family of a patient with a stroke. Which structure should the nurse identify as controlling these functions?

The nurse observes signs that a patient may be experiencing dysfunction related to the acoustic nerve (CN VIII) . Which actions should the nurse take to minimize the patient's risk for injury?

An emergency department (ED) nurse receives a report that an incoming patient has a Glasgow Coma Scale (GCS) score of 8. Which is the most appropriate action by the nurse?

The nurse is conducting a health history with a patient exhibiting signs of Parkinson disease. Which question should the nurse ask the patient?

The nurse is conducting a neurological assessment of a patient. Place an "X" on the technique the nurse should use to test for graphesthesia.

During a health assessment interview, the nurse notices the patient has a fine tremor in the right hand and arm. The patient says, "They tell me this is a primary essential tremor. What does that mean?" What is the best response by the nurse?

During a health history the nurse plans to assess the functioning of a patient's central nervous system (CNS) . Which question should the nurse ask to assess this function?

A patient experiencing extreme emotional stress is observed to be exhibiting both tachycardia and tachypnea. Which component of the patient's nervous system is responsible for normalizing the patient's response?

A patient is prescribed a medication that affects the beta₁- and beta₂-receptors in the body. Which effects of this medication should the nurse expect to assess?

Quiz 41: Assessing the Nervous System

The nurse is planning to assess a patient's brachioradialis reflex. Place an "X" on the picture that represents the technique the nurse will use to test this reflex.

The nurse reads that a patient's reflexes are 3+. How should the nurse interpret this finding?

The nurse is assessing the patient using the technique shown. Which finding should the nurse consider normal?

A patient reports hearing noises when alone in a quiet room. What action should the nurse take?

During an assessment of a patient's cranial nerves, the nurse states, "Please stick out your tongue." The nurse observes that the tongue deviates markedly to the right side. What is the patient most likely exhibiting?

The meal tray for a patient with damage to the glossopharyngeal nerve (CN IX) has been delivered. What action should the nurse take first?

The nurse is preparing to conduct an assessment of a patient's neurological status. What is the nurse assessing for in this diagram?

The nurse asks a patient who has suffered a cerebral vascular accident (CVA) to complete the heel-to-shin test. What is the nurse testing for with this technique?

The patient sustained a head injury in a fall and now is having problems seeing. Place an X on the area of the brain where the nurse suspects this patient has been injured.

The nurse is caring for a patient with lesions in the corticospinal tracts. Place an "X" on the position that the nurse should expect to assess in this patient?

The nurse is reviewing the part of the nervous system that controls cardiac rate, blood pressure, respiration, and swallowing with the family of a patient with a stroke. Which structure should the nurse identify as controlling these functions?

The nurse observes signs that a patient may be experiencing dysfunction related to the acoustic nerve (CN VIII) . Which actions should the nurse take to minimize the patient's risk for injury?

An emergency department (ED) nurse receives a report that an incoming patient has a Glasgow Coma Scale (GCS) score of 8. Which is the most appropriate action by the nurse?

The nurse is conducting a health history with a patient exhibiting signs of Parkinson disease. Which question should the nurse ask the patient?

The nurse is conducting a neurological assessment of a patient. Place an "X" on the technique the nurse should use to test for graphesthesia.

During a health assessment interview, the nurse notices the patient has a fine tremor in the right hand and arm. The patient says, "They tell me this is a primary essential tremor. What does that mean?" What is the best response by the nurse?

During a health history the nurse plans to assess the functioning of a patient's central nervous system (CNS) . Which question should the nurse ask to assess this function?

A patient experiencing extreme emotional stress is observed to be exhibiting both tachycardia and tachypnea. Which component of the patient's nervous system is responsible for normalizing the patient's response?

A patient is prescribed a medication that affects the beta1- and beta2-receptors in the body. Which effects of this medication should the nurse expect to assess?

A patient is prescribed a medication that affects the beta₁- and beta₂-receptors in the body. Which effects of this medication should the nurse expect to assess?