Deck 47: Neurologic System Function,Assessment,and Therapeutic Measures

Question 1

The nurse is caring for a patient who has impaired functioning of the left glossopharyngeal (IX)nerve and the vagus (X)nerve.What intervention should the nurse plan to maintain the patient's safety while diagnostic testing is being completed?

A) Insert an oral airway.
B) Withhold oral fluid or foods.
C) Obtain a picture board and a Magic Slate.
D) Apply eye patches to keep the eyes closed.

Answer 1

Withhold oral fluid or foods.

Question 2

The nurse is preparing material about impulse transmission to help with a presentation on the neurological system.When discussing spinal nerves,the nurse will include that each spinal nerve is made up of the dorsal root and which other root?

A) Medial
B) Lateral
C) Ventral
D) Proximal

Answer 2

Ventral

Question 3

The nurse is caring for a patient diagnosed with a cerebral tumor.For which function should the nurse expect to assess an abnormality?

A) Reflex movement
B) Movement and speech
C) Coordination and posture
D) Heart rate and respiratory rate

Answer 3

Movement and speech

Question 4

A neurologist asks a patient to stick out the tongue.Which cranial nerve (CN)is being tested?

A) VII (facial)
B) I (olfactory)
C) IV (trochlear)
D) XII (hypoglossal)

Question 5

A patient is diagnosed with a health problem that alters the way impulses are conducted in the neurological system.When reviewing this information with the patient,which part of a neuron should the nurse teach carries impulses toward the cell body?

A) Axon
B) Dendrite
C) Schwann cell
D) Myelin sheath

Question 6

The nurse notes that a patient is not able to voluntary move the right arm.Which part of the brain should the nurse suspect is affected in this patient?

A) Cerebellum
B) Frontal lobe
C) Parietal lobe
D) Hypothalamus

Question 7

The nurse is reviewing the results of a patient's diagnostic tests which show changes in nerve insulation.What structure should the nurse explain to the patient that electrically insulates neurons?

A) Astrocytes
B) Gray matter
C) Interneurons
D) Myelin sheath

Question 8

A patient reports nearly having a motor vehicle crash and states that his heart was pounding and he was breathing heavy and fast.Currently the patient's heart rate and breathing are within normal limits.Which neurotransmitter has resumed control after the patient's incident?

A) Serotonin
B) Prostaglandin
C) Acetylcholine
D) Norepinephrine

Question 9

The nurse is assisting a neurologist with assessment of a patient with facial muscle weakness.When the neurologist asks the patient to identify different odors,which nerve is being tested?

A) II (optic)
B) X (vagus)
C) I (olfactory)
D) VIII (acoustic)

Question 10

The nurse is caring for a patient admitted to the emergency room after a motor vehicle crash.Which assessment is most important for the nurse to complete?

A) Babinski test
B) Romberg test
C) Glasgow Coma Scale
D) Visual analogue scale

Question 11

The nurse is preparing a patient for an electroencephalogram (EEG).What information should be given to the patient?

A) Little needles will be stuck into the scalp.
B) The hair must be clean and dry before the test.
C) The hair at the temporal area will have to be shaved.
D) The patient must withhold fluids and food for 12 hours before the test.

Question 12

The nurse is reviewing the vital sign measurements for a patient with a neurological problem.When analyzing these measurements what should the nurse recall as the part of the brain that regulates heart rate and blood pressure?

A) Medulla
B) Cerebrum
C) Cerebellum
D) Hypothalamus

Question 13

The nurse is preparing material about the neurological system as part of major presentation.What should the nurse include that explains the purpose of white matter?

A) Carries either sensory or motor impulses
B) Location of white blood cells within the brain
C) Protects the spinal nerves from potential injury
D) Regulates movement and responses to external stimuli

Question 14

The nurse is caring for an individual with a head injury and notes unequal pupils.Which term should the nurse use to document this finding?

A) Aphasia
B) Nystagmus
C) Anisocoria
D) Ophthalmoplegia

Question 15

A patient learns that abdominal pain is originating from the liver.The nurse should explain to the patient that the impulses from receptors in the internal organs to the central nervous system are transmitted from which type of neurons?

A) Interneurons
B) Efferent neurons
C) Somatic sensory neurons
D) Visceral sensory neurons

Question 16

The nurse is caring for a patient who is scheduled for a computed tomography (CT)scan of the brain because of new onset of headaches.Which statement by the nurse is most accurate when preparing the patient for the scan?

A) "You must shampoo your hair thoroughly tonight to remove oil and dirt."
B) "You will need to hold your head completely still during the examination."
C) "You may take fluids until about 8 a.m. Then we will give you a special radiopaque drink."
D) "We will partially shave your head tonight so that electrodes can be attached securely to your scalp."

Question 17

The nurse is assessing a patient's pupils for reactivity to light.Which cranial nerve (CN)is being tested?

A) CN III
B) CN IV
C) CN VI
D) CN XII

Question 18

A 22-year-old female patient recovering from a craniotomy begins crying and asking for her mother who is sleeping in the visitor's lounge.The patient's Glasgow Coma Scale (GCS)of 15 and pupils are equal and reactive.What nursing action would be most appropriate at this time?

A) Ask the mother to come and stay with the patient.
B) Administer an as-needed sedative to calm the patient.
C) Notify the neurosurgeon that the patient is upset and crying.
D) Reassure the patient, and sit with her until she falls back asleep.

Question 19

The nurse notes that a patient has a history of falling.Which part of the brain should the nurse question as being affected in this patient?

A) Medulla
B) Cerebellum
C) Frontal lobes
D) Hypothalamus

Question 20

The nurse is explaining the transmission of nerve impulses to a patient with a spinal cord injury.What should the nurse explain as the structure that carries nerve impulses at synapses?

A) Cell membrane
B) Depolarizations
C) Schwann's cells
D) Neurotransmitters

Question 21

A patient who is severely brain damaged has decerebrate posturing with extended extremities.In which area of the brain should the nurse suspect the patient has sustained damage?

A) Cerebrum
B) Brain stem
C) Cerebellum
D) Hypothalamus

Question 22

The nurse is caring for a patient who is scheduled for a magnetic resonance imaging (MRI)scan.What explanation should be provided to the patient and family?

A) "A scan of the brain will be done after injection of a radioisotope."
B) "An MRI uses electrodes placed on the scalp to measure activity of the brain."
C) "An MRI measures muscle contraction after stimulation by tiny needle electrodes."
D) "An MRI is a noninvasive test that uses magnetic energy to visualize internal parts."

Question 23

A patient becomes startled when the alarm rings for a fire drill.After reassuring the patient that there is no danger,an assessment is completed.Which finding may be related to a sympathetic response?

A) Wheezing
B) Confusion
C) Incontinence
D) Diminished bowel sounds

Question 24

The nurse completes data collection on a newly admitted older patient.Which finding is considered abnormal in an aging patient and should be reported to the physician? (Select all that apply.)

A) Depression
B) Forgetfulness
C) Altered sleep patterns
D) Decreased postural stability
E) Fine motor tremors of the hands
F) Decreased problem-solving ability

Question 25

The nurse is providing care for an 87-year-old woman who is recovering from a cerebral vascular accident.Which precaution should the nurse take after noting the patient has a positive Romberg test?

A) Institute fall-risk precautions.
B) Provide small, frequent meals.
C) Request a footboard and splints.
D) Darken the room and reduce stimuli.

Question 26

The nurse is preparing to conduct a Romberg test with a patient.For how many seconds should the nurse explain to the patient that the position will need to be held?

A) 10
B) 20
C) 30
D) 40

Question 27

The nurse is explaining the neurological system to a group of nursing students.How many pairs of spinal nerves should the nurse explain are contained within the human body?

A) 15
B) 25
C) 31
D) 42

Question 28

When the nurse shines a light in a patient's left pupil,both of the pupils constrict.What type of response should the nurse document?

A) Direct
B) Abnormal
C) Consensual
D) Accommodation

Question 29

The nurse suspects a patient is experiencing a sympathetic response.What manifestations should the nurse expect the patient to demonstrate this response? (Select all that apply.)

A) Relaxation of bladder
B) Decrease in peristalsis
C) Dilation of bronchioles
D) Decrease in heart rate to normal
E) Increase in salivary gland secretion

Question 30

The nurse suspects that a patient will be diagnosed as being in a comatose state based upon the Glasgow Coma Scale score.What score does the patient need to have to be identified as comatose?

A) 7
B) 9
C) 11
D) 13

Question 31

The nurse is assisting as a neurosurgeon examines a patient who has a positive Babinski reflex.What assessment finding should the nurse expect to observe?

A) The leg flexes when the patellar tendon is struck.
B) The leg extends when the patellar tendon is struck.
C) The big toe extends when the sole of the foot is stroked.
D) Toes curl downward when the sole of the foot is stroked.

Question 32

A patient is scheduled for a lumbar puncture.Which action should the nurse take when preparing this patient?

A) Remove all metal jewelry.
B) Administer enemas until clear.
C) Remove the patient's dentures.
D) Assist the patient into a side-lying position.

Question 33

The nurse is caring for a patient scheduled for a computed tomography (CT)scan with contrast.What should be included in pre-procedure preparation? (Select all that apply.)

A) Check blood urea nitrogen (BUN) and creatinine levels.
B) Question the patient about allergies to dye, shellfish, or iodine.
C) Determine if the patient has aneurysm clips or metal pins in the body.
D) Explain to the patient that a sensation of warmth may be felt when dye is injected.
E) Tell the patient to report any nausea, itchiness, or difficulty breathing during the scan.

Question 34

The nurse is participating in the preparation of a seminar on the neurologic system for a community health fair.Which part of the system is the nurse referring when the statement "rest and digest" is included?

A) Left hemisphere of the cerebral cortex
B) Right hemisphere of the cerebral cortex
C) Sympathetic division of the autonomic nervous system
D) Parasympathetic division of the autonomic nervous system

Question 35

The nurse is caring for a patient who has had a stroke (brain attack).The patient is unable to understand what the nurse is saying and appears frustrated.What term should the nurse use to document this finding?

A) Dysphagia
B) Confusion
C) Receptive aphasia
D) Expressive aphasia

Question 36

A patient opens the eyes to painful stimuli,makes incomprehensible sounds,and withdraws from pain.What should the nurse calculate this patient's Glasgow Coma Scale score to be?

A) 2
B) 4
C) 6
D) 8

Question 37

The nurse is providing post-procedure care for a patient recovering from a lumbar puncture.Which order should the nurse anticipate for this patient?

A) Keep the patient NPO for 4 hours.
B) Have the patient lie flat for 6 hours.
C) Monitor the patient's pedal pulses every 4 hours.
D) Keep the head of the bed elevated 30 degrees for 8 hours.

Question 38

While collecting data the nurse learns that a patient with a neurological illness has not had a sense of smell for several decades.Which part of the central nervous system should the nurse question as being damaged in this patient?

A) Brainstem
B) Occipital lobe
C) Hypothalamus
D) Temporal lobe

Question 39

The nurse is providing care for a client admitted to the hospital after a motor vehicle accident.After being informed by family members that the patient is deaf and mute,which action should the nurse take?

A) Avoid use of the Glasgow Coma Scale.
B) Consider the Babinski response invalid.
C) Utilize a three-point scale to grade muscle strength.
D) Perform the Romberg test with the patient in a seated position.

Question 40

The nurse is providing care for a patient with a history of aspiration.Which foods should the nurse remove from patient's tray? (Select all that apply.)

A) Coffee
B) Ice cream
C) Fruit juice
D) Applesauce
E) Ground chicken
F) Bread with butter

Question 41

The nurse is planning to use the FOUR tool to assess a patient's neurological functioning.In which areas should the nurse collect data when using this tool? (Select all that apply.)

A) Reflexes
B) Eye response
C) Verbal response
D) Motor movement
E) Breathing pattern

Question 42

The nurse is preparing a review of the neurological system as part of a community health presentation.Which structures should the nurse identify as being part of the diencephalon? (Select all that apply.)

A) Pons
B) Medulla
C) Thalamus
D) Brainstem
E) Hypothalamus

Question 43

The nurse is caring for a patient scheduled for a lumbar puncture.Which actions should the nurse anticipate providing? (Select all that apply.)

A) Position the patient prone on the bed.
B) Check the puncture site for swelling or drainage.
C) Ensure that the patient has given informed consent to the procedure.
D) Keep the patient on bedrest with the head of the bed flat for 6 hours after the procedure.
E) Limit fluid intake.
F) Assess movement and sensation of lower extremities frequently for several hours after the procedure.

Question 44

While observing the neurologist complete a neurological examination the nurse notes that a patient does not have a left patellar reflex.In which areas should the nurse consider the patient has a dysfunction? (Select all that apply.)

A) Spinal cord
B) Femoral nerve
C) Anterior fibula muscle
D) Posterior tibial muscle
E) Quadriceps femoris muscle

Question 45

A patient is surprised to learn that cerebrospinal fluid will be removed during a lumbar puncture and asks the purpose of the fluid.What should the nurse explain to the patient? (Select all that apply.)

A) Interprets sensory information
B) Provides oxygen to the brain tissue
C) Cushions the central nervous system
D) Conducts electrical impulses between brain hemispheres
E) Exchanges nutrients and wastes between the blood and neurons