Question 1

The nurse is caring for a patient with a head injury who is obtunded.The nurse is going to use noxious stimuli to elicit a response.What is an acceptable method?
A) Nipple pinch
B) Nail bed pressure
C) Supraorbital pressure
D) Sternal rub

Accepted Answer

Nail bed pressure and trapezius pinch are acceptable methods of noxious stimulation.Nail bed pressure allows evaluation of individual extremity function.Trapezius pinch is difficult to perform on large or obese adults.Repeated sternal rub can cause the sternum to become excoriated,open,and infected.Supraorbital pressure must be avoided in patients with head injuries,frontal craniotomies,or facial surgery.Nipple and testicle pinching are inappropriate and unnecessary.

Question 2

The nurse knows that change in pupil size is a significant neurologic finding particularly in the patient with a head injury.How much of a size difference between the two pupils is still considered normal?
A) 1 mm
B) 1.5 mm
C) 2 mm
D) 2.5 mm

Accepted Answer

Pupil size should be documented in millimeters with the use of a pupil gauge to reduce the subjectivity of description.Most people have pupils of equal size,between 2 and 5 mm.A discrepancy up to 1 mm between the two pupils is normal.

Question 3

A patient is admitted with an anoxic brain injury.The nurse notes abnormal extension of both extremities to noxious stimuli.This finding indicates dysfunction in which area of the central nervous system?
A) Cerebral cortex
B) Thalamus
C) Cerebellum
D) Brainstem

Accepted Answer

Abnormal extension occurs with lesions in the area of the brainstem.Abnormal flexion occurs with lesions above the midbrain in the region of the thalamus or cerebral hemispheres.

Question 4

Which of the following statements best describes assessment of arousal?
A) It measures content of consciousness and is a higher-level function.
B) It is an evaluation of the reticular activating system and its connection with the thalamus and the cerebral cortex.
C) It becomes a valid parameter when the patient is able to respond to verbal stimuli, such as squeezing the hands on command.
D) Noxious stimuli are not to be used as an assessment parameter.

Accepted Answer

Assessment of the arousal component of consciousness is an evaluation of the reticular activating system and its connection with the thalamus and the cerebral cortex.Arousal is the lowest level of consciousness,and observation centers on the patient's ability to respond to verbal or noxious stimuli in an appropriate manner.

Question 5

The nurse is precepting a nursing student.The student asks about testing of extraocular eye movements.What should the nurse tell the student?
A) It tests the pupillary response to light.
B) It tests function of the three cranial nerves.
C) It tests the ability of the eyes to accommodate to a closer moving object.
D) It tests the oculocephalic reflex.

Accepted Answer

Control of eye movements occurs with interaction of three cranial nerves: oculomotor (III),trochlear (IV),and abducens (VI).

Question 6

The nurse is precepting a new graduate nurse.The new graduate asks about testing the oculovestibular reflex.What should the nurse tell the new graduate?
A) The test should not be performed on an unconscious patient because of the risk of aspiration.
B) An abnormal response is manifested by conjugate, slow, tonic nystagmus, deviating toward the irrigated ear.
C) This test should be included in the nursing neurologic examination of a patient with a head injury.
D) This test is one of the final clinical assessments of brainstem function.

Accepted Answer

The oculovestibular reflex is one of the final clinical assessments of brainstem function and is only performed by a practitioner.After confirmation that the tympanic membrane is intact,the head is raised to a 30-degree angle.Then 20 to 100 mL of ice water is injected into the external auditory canal.In a normal response,eye movement is in the direction of the injection site.An abnormal response is disconjugate eye movement,which indicates a brainstem lesion,or no response,which indicates little to no brainstem function.

Question 7

The nurse is caring for a severely head injured comatose patient who is dying.The nurse knows the patient has entered the late stages of intracranial hypertension when the nurse observes which signs?
A) Pupils are equal and reactive
B) Widening pulse pressure
C) Eupnea
D) Decreased intracranial pressure

Accepted Answer

Attention must also be paid to the pulse pressure because widening of this value may occur in the late stages of intracranial hypertension.With the loss of autoregulation as blood pressure increases,cerebral blood flow (CBF)and cerebral blood volume increase and intracranial pressure (ICP)therefore increases.The mean arterial pressure must be maintained at a level sufficient to produce adequate CBF in the presence of elevated ICP.

Question 8

While the Glasgow Coma Scale (GCS)is part of the routine neurologic assessment,the nurse knows that it is not a valid measure for certain types of patients.In which patient is the GCS not valid?
A) Patient with hemiplegia
B) Patient with Parkinson disease
C) Patient with dyslexia
D) Patient who is intoxicated

Accepted Answer

Several points should be kept in mind when the Glasgow Coma Scale is used for serial assessment.It provides data about level of consciousness only,and it should never be considered a complete neurologic examination.Additionally,it is not a sensitive tool for evaluation of an altered sensorium,and it does not account for possible aphasia or mechanical intubation.It is also a poor indicator of lateralization of neurologic deterioration

Question 9

The nurse is caring for a patient who has sustained a traumatic head injury.The practitioner has asked the nurse to test the patient's oculocephalic reflex.Which findings indicate that the patient has an intact oculocephalic reflex?
A) The patient's eyes move in the same direction the head is turned.
B) The patient's eyes move in the opposite direction to the movement of the patient's head.
C) The patient's eyes rove and move in opposite directions from each other.
D) The patient's eyes move up and down and then back and forth.

Accepted Answer

To assess the oculocephalic reflex,the nurse holds the patient's eyelids open and briskly turns the head to one side while observing the eye movements and then briskly turns the head to the other side and observes.If the eyes deviate to the opposite direction in which the head is turned,doll's eyes are present,and the oculocephalic reflex arc is intact.If the oculocephalic reflex arc is not intact,the reflex is absent.

Question 10

The nurse is caring for a patient with a closed head injury with a Glasgow Coma Scale (GCS)score of 6.What does this score indicate about the patient's neurologic status?
A) Patient is in a vegetative state.
B) Patient is a paraplegic.
C) Patient is in a coma.
D) Patient is able to obey commands.

Accepted Answer

The best possible score on the Glasgow Coma Scale (GCS)is 15,and the lowest score is 3.Generally,a score of 7 or less on the GCS indicates coma.Originally,the scoring system was developed to assist in general communication concerning the severity of neurologic injury.

Question 11

A patient is admitted to the critical care unit with a subdural hematoma.The nurse is assessing the patient's Glasgow Coma Scale (GCS)score.Which statement is true concerning the GCS?
A) It provides data about level of consciousness only.
B) It is considered equivalent to a complete neurologic examination.
C) It is a sensitive tool for evaluation of an altered sensorium.
D) It is the most critical assessment parameter to account for possible aphasia.

Accepted Answer

Several points should be kept in mind when the Glasgow Coma Scale is used for serial assessment.It provides data about level of consciousness only,and it should never be considered a complete neurologic examination.Additionally,it is not a sensitive tool for evaluation of an altered sensorium,and it does not account for possible aphasia or mechanical intubation.It is also a poor indicator of lateralization of neurologic deterioration.

Question 12

The nurse is caring for a patient who has sustained a traumatic head injury.The practitioner has asked the nurse to test the patient's oculocephalic reflex.What must the nurse verity prior to performing the test?
A) The absence of cervical injury
B) The depth and rate of respiration
C) The patient's ability to swallow
D) The patient's ability to follow a verbal command

Accepted Answer

In an unconscious patient,assessment of ocular function and innervation of the medial longitudinal fasciculus (MLF)is performed by eliciting the doll's eyes reflex.If the patient is unconscious as a result of trauma,the nurse must ascertain the absence of cervical injury before performing this examination.

Question 13

The nurse is caring for a patient with a head injury and observes a rhythmic increase and decrease in the rate and depth of respiration followed by brief periods of apnea.What should the nurse document under breathing pattern?
A) Central neurogenic hyperventilation
B) Apneustic breathing
C) Ataxic respirations
D) Cheyne-Stokes respirations

Accepted Answer

Cheyne-Stokes respirations have a rhythmic crescendo and decrescendo of rate and depth of respiration,including brief periods of apnea.These respirations are usually seen with bilateral deep cerebral lesions or some cerebellar lesions.Central neurogenic hyperventilations are very deep,very rapid respirations with no apneic periods.They are usually seen with lesions of the midbrain and upper pons.Apneustic breathing includes clusters of irregular,gasping respirations separated by long periods of apnea.They are usually seen in lesions of the lower pons or upper medulla.Ataxic respirations are irregular,random patterns of deep and shallow respirations with irregular apneic periods.They are usually seen in lesions of the medulla.

Question 14

The nurse is caring for a patient immediately after a craniotomy.When assessing the size and shape of the patient's pupils the nurse notes the patient's left pupil is oval.What does this finding indicate?
A) Cortical dysfunction
B) Intracranial hypertension
C) Hydrocephalus
D) Metabolic coma

Accepted Answer

Pupil shape is also noted in the assessment of pupils.Although the pupil is normally round,an irregularly shaped or oval pupil may be noted in patients with eye surgery.Initial stages of cranial nerve III compression from elevated intracranial pressure can also cause the pupil to have an oval shape.

Question 15

The nurses are admitting a neurologically impaired patient.The patient's family is present.How comprehensive should the initial history be?
A) It should be limited to the chief complaint and personal habits.
B) It should be all-inclusive, including events preceding hospitalization.
C) It should be confined to current medications and family history.
D) It should be restricted to only information that the patient can provide.

Accepted Answer

The one factor common to all neurologic assessment is the need to obtain a comprehensive history of events preceding hospitalization.

Question 16

The nurse is caring for a severely head injured comatose patient who is dying.The practitioner asks to be notified when the patient starts to exhibit signs of Cushing reflex.The nurse would call the practitioner when the patient starts to show what signs?
A) Bradycardia, systolic hypertension, and widening pulse pressure
B) Tachycardia, systolic hypotension, and tachypnea
C) Headache, nuchal rigidity, and hyperthermia
D) Bradycardia, aphasia, and visual field disturbances

Accepted Answer

The Cushing reflex is a set of three clinical manifestations (bradycardia,systolic hypertension,and widening pulse pressure)related to pressure on the medullary area of the brainstem.

Question 17

Why is assessment of level of conscious (LOC)the most important aspect of the neurologic examination?
A) The LOC is the most prognostic indicator of the patient's outcome.
B) The LOC is generally limited to the Glasgow Coma Scale making it the quickest part of the assessment.
C) In most situations the LOC deteriorates before any other neurologic changes are noted.
D) The LOC is the easiest part of the neurologic exam and thus is generally performed first.

Accepted Answer

Assessment of the level of consciousness is the most important aspect of the neurologic examination.

Question 18

A patient with a serious head injury has been admitted.The nurse knows that certain neurologic findings can indicate the prognosis for the patient.Which finding denotes the most serious prognosis?
A) Decorticate posturing
B) Decerebrate posturing
C) Absence of Babinski reflex
D) Glasgow Coma Scale (GCS) score of 14

Accepted Answer

Outcome studies indicate that abnormal flexion or decorticate posturing has a less serious prognosis than does extension,or decerebrate posturing.Onset of posturing or a change from abnormal flexion to abnormal extension requires immediate physician notification.The Babinski reflex is a pathologic finding; absence of this reflex is a normal neurologic finding in adults.The range of scores for the Glasgow Coma Scale is 3 to 15.A score of 14 denotes a minimal deficit.

Question 19

The nurse is caring for a critically injured patient who can only be aroused by vigorous external stimuli.Which category should the nurse use to document the patient's level of consciousness?
A) Lethargic
B) Obtunded
C) Stuporous
D) Comatose

Accepted Answer

Stuporous means the patient can be aroused only by vigorous and continuous external stimuli.Motor response is often withdrawal or localizing to stimulus.Obtunded means the patient displays dull indifference to external stimuli,and response is minimally maintained.Questions are answered with a minimal response.Lethargic means the patient displays a state of drowsiness or inaction in which the patient needs an increased stimulus to be awakened.Comatose means vigorous stimulation fails to produce any voluntary neural response in the patient.

Question 20

The nurse is starting a peripheral intravenous catheter in the right hand of an unconscious patient.During the procedure the patient reaches over with his left hand and tries to remove the noxious stimuli.How would the nurse document this response?
A) Decorticate posturing
B) Decerebrate posturing
C) Withdrawal
D) Localization

Accepted Answer

Localization occurs when the extremity opposite to the extremity receiving pain crosses the midline of the body in an attempt to remove the noxious stimulus from the affected limb.

Quiz 22: Neurologic Clinical Assessment and Diagnostic Procedures

The nurse is caring for a patient with a head injury who is obtunded.The nurse is going to use noxious stimuli to elicit a response.What is an acceptable method?

The nurse knows that change in pupil size is a significant neurologic finding particularly in the patient with a head injury.How much of a size difference between the two pupils is still considered normal?

A patient is admitted with an anoxic brain injury.The nurse notes abnormal extension of both extremities to noxious stimuli.This finding indicates dysfunction in which area of the central nervous system?

Which of the following statements best describes assessment of arousal?

The nurse is precepting a nursing student.The student asks about testing of extraocular eye movements.What should the nurse tell the student?

The nurse is precepting a new graduate nurse.The new graduate asks about testing the oculovestibular reflex.What should the nurse tell the new graduate?

The nurse is caring for a severely head injured comatose patient who is dying.The nurse knows the patient has entered the late stages of intracranial hypertension when the nurse observes which signs?

While the Glasgow Coma Scale (GCS) is part of the routine neurologic assessment,the nurse knows that it is not a valid measure for certain types of patients.In which patient is the GCS not valid?

The nurse is caring for a patient who has sustained a traumatic head injury.The practitioner has asked the nurse to test the patient's oculocephalic reflex.Which findings indicate that the patient has an intact oculocephalic reflex?

The nurse is caring for a patient with a closed head injury with a Glasgow Coma Scale (GCS) score of 6.What does this score indicate about the patient's neurologic status?

A patient is admitted to the critical care unit with a subdural hematoma.The nurse is assessing the patient's Glasgow Coma Scale (GCS) score.Which statement is true concerning the GCS?

The nurse is caring for a patient who has sustained a traumatic head injury.The practitioner has asked the nurse to test the patient's oculocephalic reflex.What must the nurse verity prior to performing the test?

The nurse is caring for a patient with a head injury and observes a rhythmic increase and decrease in the rate and depth of respiration followed by brief periods of apnea.What should the nurse document under breathing pattern?

The nurse is caring for a patient immediately after a craniotomy.When assessing the size and shape of the patient's pupils the nurse notes the patient's left pupil is oval.What does this finding indicate?

The nurses are admitting a neurologically impaired patient.The patient's family is present.How comprehensive should the initial history be?

The nurse is caring for a severely head injured comatose patient who is dying.The practitioner asks to be notified when the patient starts to exhibit signs of Cushing reflex.The nurse would call the practitioner when the patient starts to show what signs?

Why is assessment of level of conscious (LOC) the most important aspect of the neurologic examination?

A patient with a serious head injury has been admitted.The nurse knows that certain neurologic findings can indicate the prognosis for the patient.Which finding denotes the most serious prognosis?

The nurse is caring for a critically injured patient who can only be aroused by vigorous external stimuli.Which category should the nurse use to document the patient's level of consciousness?

The nurse is starting a peripheral intravenous catheter in the right hand of an unconscious patient.During the procedure the patient reaches over with his left hand and tries to remove the noxious stimuli.How would the nurse document this response?