Deck 56: Nursing Assessment: Nervous System

Question 1

Which equipment will the nurse obtain to assess vibration sense in a patient who has peripheral nerve dysfunction?

A) Sharp pin
B) Tuning fork
C) Reflex hammer
D) Calibrated compass

Answer 1

Tuning fork

Question 2

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

A) apply a cotton wisp strand to the cornea.
B) have the patient read a magazine or book.
C) shine a bright light into the patient's pupil.
D) check for unilateral drooping of the eyelids.

Answer 2

apply a cotton wisp strand to the cornea.

Question 3

A patient with a brainstem infarction is admitted to the nursing unit. The priority nursing assessment for the patient is

A) reflex reaction time.
B) pupil reaction to light.
C) level of consciousness.
D) respiratory rate and rhythm.

Answer 3

respiratory rate and rhythm.

Question 4

Neurologic testing of the patient indicates impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). Which action will the nurse include in the plan of care?

A) Insert an oral airway.
B) Withhold oral fluid or foods.
C) Provide highly seasoned foods.
D) Apply artificial tears every hour.

Question 5

A patient has a lesion that affects lower motor neurons. During assessment of the patient's lower extremities, the nurse expects to find

A) spasticity.
B) flaccidity.
C) loss of sensation.
D) hyperactive reflexes.

Question 6

Which information about a 71-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) Recent unintended weight loss of 20 pounds
C) Patient complaint of chronic difficulty in falling asleep
D) Orthostatic drop in systolic blood pressure of 10 mm Hg

Question 7

A patient is hospitalized with a possible seizure disorder. To determine the cause of the patient's symptoms, the nurse will anticipate the need to teach the patient about which of these tests?

A) Cerebral angiography
B) Evoked potential studies
C) Electromyography (EMG)
D) Electroencephalography (EEG)

Question 8

A patient is scheduled for a lumbar puncture. The nurse will plan to

A) transfer the patient to radiology just before the procedure.
B) help the patient to a side lying position before the procedure.
C) place the patient on NPO status for 4 hours before the procedure.
D) administer a sedative medication 30 minutes before the procedure.

Question 9

Propranolol (Inderal), a ?-adrenergic blocker that inhibits sympathetic nervous system activity, is prescribed for a patient. The nurse monitors the patient for

A) dry mouth.
B) constipation.
C) slowed pulse.
D) urinary retention.

Question 10

When admitting an acutely confused 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 11

The nurse notes in the patient's medical history that the patient has a positive Romberg test. Which nursing diagnosis is appropriate?

A) Acute pain related to hyperreflexia and spasm
B) Risk for falls related to dizziness or weakness
C) Disturbed tactile sensory perception related to spinal cord damage
D) Ineffective thermoregulation related to decreased vasomotor response

Question 12

Which assessments will the nurse make to test a patient's cerebellar function (select all that apply)?

A) Assess for graphesthesia.
B) Perform the finger-to-nose test.
C) Observe arm movement with gait.
D) Check ability to push against resistance.
E) Determine ability to sense heat and cold.

Question 13

After reviewing a patient's cerebrospinal fluid analysis, which 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 ( 0.30 g/L )
C) White blood cell ( WBC ) count 4/?L
D) Glucose 45 mg/dL ( 1.7 mmol/L )

Question 14

The charge nurse is observing a new staff nurse who is assessing a patient with a possible spinal cord lesion for sensation. Which action indicates a need for further teaching about neurologic assessment?

A) The new nurse asks the patient, "Does this feel sharp?"
B) The new nurse tests for light touch before testing for pain.
C) The new nurse has the patient close the eyes during testing.
D) The new nurse uses an irregular pattern to test for intact touch.

Question 15

When performing a focused assessment on a patient with a lesion of the left posterior temporal lobe, the nurse will assess for

A) sensation on the left side of the body.
B) voluntary movement on the right side.
C) reasoning and problem-solving abilities.
D) understanding of written and oral language.

Question 16

A patient is scheduled for a myelogram to confirm the presence of a herniated intervertebral disk. Which information obtained when admitting the patient 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 had 4 ounces of apple juice 4 hours earlier.
D) The patient has back pain when lying flat for long periods.

Question 17

The following orders are received for an unconscious patient who has just arrived in the emergency department after a head injury caused by an automobile accident. Which one 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.

Question 18

When developing a plan of care for a patient with dysfunction of the cerebellum, the nurse will include interventions to

A) prevent falls.
B) stabilize mood.
C) enhance swallowing ability.
D) improve short-term memory.

Question 19

During the neurologic assessment, the patient cooperates with the nurse's directions to grip with the hands and to move the feet but is unable to respond orally to the nurse's questions. The nurse will suspect

A) a brainstem lesion.
B) a temporal lobe lesion.
C) injury to the cerebellum.
D) damage to the frontal lobe.

Question 20

When caring for a patient who has had cerebral angiography, which nursing action will be included in the plan of care?

A) Ask about 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.