Deck 56: Nursing Assessment: Nervous System

Question 1

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.

Answer 1

Check pulse and blood pressure frequently.

Question 2

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.

Answer 2

Prepare the patient for lumbar puncture.

Question 3

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

Answer 3

Tuning fork

Question 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.

Question 5

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)

Question 6

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.

Question 7

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.

Question 8

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

A) shine a light into the patient's 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.

Question 9

Which information about a 76-year-old patient is most important for the admitting nurse to report to the patient's 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

Question 10

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.

Question 11

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

Question 12

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.

Question 13

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.

Question 14

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.

Question 15

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

Question 16

During the neurologic assessment,the patient is unable to respond verbally to the nurse but cooperates with the nurse's 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.

Question 17

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

A) Ask family members about the patient's 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.

Question 18

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

Question 19

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

Question 20

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.

Question 21

Which assessments will the nurse make to monitor a patient's cerebellar function ?

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.