Question 1

The nurse is providing an informational session on stroke at a community health centre and includes the following risk factors that should be modified to decrease risk for stroke: (Select all that apply.)

Accepted Answer

The following modifiable risk factors for stroke have been well documented:
1.History of cardiovascular disease:
a.Coronary artery disease (CAD)
b.Cardiac failure
c.Symptomatic peripheral artery disease (PAD)
2.Hypertension
3.Cigarette smoking or exposure to second-hand smoke
4.Diabetes
5.Atrial fibrillation
6.Other cardiac conditions:
a.Dilated cardiomyopathy
b.Valvular heart disease (e.g., mitral valve prolapse, endocarditis, and prosthetic cardiac valves)
c.Intracardiac congenital defects (e.g., patent foramen ovale, atrial septal defect, and atrial septal aneurysm)
7.Dyslipidemia
8.Asymptomatic carotid stenosis
9.Sickle cell disease
10.Postmenopausal hormone therapy
11.Diet and nutrition
12.Physical inactivity
13.Obesity and fat distribution
14.History of transient ischemic attack (TIA)

Question 2

The nurse is reviewing a patient's medical record and notes that he is in a coma.Using the Glasgow Coma Scale, which number indicates that the patient is in a coma?

Accepted Answer

According to the Glasgow Coma Scale, a score of 8 or less indicates a coma. Choice A, with a score of 6, is the only option that falls within this range. Choices B, C, and D all have scores that indicate varying levels of consciousness, but not a coma.

Question 3

To encourage quick response when observing someone experiencing symptoms of a stroke, the nurse uses the mnemonic:

Accepted Answer

To promote swift recognition of the symptoms of stroke among members of the public, the Heart and Stroke Foundation of Canada developed the following mnemonic:
•Face-Is it drooping?
•Arms-Can you raise both?
•Speech-Is it slurred or jumbled?
•Time-To call 9-1-1 right away.
Act FAST because the quicker you act, the more of the person you will save.

Question 4

A 59-year-old patient has a herniated intervertebral disc.Which of the following findings should the nurse expect to see on physical assessment of this individual?

Accepted Answer

A herniated intervertebral disc can compress spinal nerve roots, leading to decreased reflexes such as hyporeflexia. Increased muscle tone, a positive Babinski sign, and the presence of pathological reflexes are not typically associated with a herniated disc.

Question 5

The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)?

Accepted Answer

The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement.The other structures are not responsible for a person's level of consciousness.

Question 6

The nurse knows that testing kinesthesia is a test of a person's:

Accepted Answer

Kinesthesia, or position sense, is the person's ability to perceive passive movements of the extremities.The other options are incorrect.

Question 7

During examination, the nurse notices severe back and forth oscillations in both eyes of the patient.Which conclusion by the nurse is correct regarding the findings? This:

Accepted Answer

End-point nystagmus (back and forth oscillations of the eyes) at an extreme lateral gaze normally occurs; however, the nurse should carefully assess any other nystagmus.Severe nystagmus occurs with disease of the vestibular system, cerebellum, or brainstem.

Question 8

During the assessment of DTRs, the nurse finds that a patient's responses are bilaterally normal.What number is used to indicate normal DTRs when the documenting this finding? __________+

Accepted Answer

The answer of During the assessment of DTRs, the nurse...

Question 9

During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms.His palms pronate, and his lower extremities extend with plantar flexion.Which statement concerning these findings is most accurate? This patient's response:

Accepted Answer

These findings are all indicative of decerebrate rigidity, which is a very ominous condition and may indicate a brainstem injury.

Question 10

The nurse is working at a blood pressure clinic with a multicultural community.The nurse ensures to provide health education resources on stroke, especially to certain individuals who are from the following ethnocultural backgrounds and have a greater risk for stroke: (Select all that apply.)

Accepted Answer

Indigenous people and people of African or South Asian descent are more likely to have high blood pressure and diabetes and are therefore at greater risk for heart disease and stroke compared with the general population.Recognizing the importance of early detection of stroke, the Heart and Stroke Foundation of Canada has translated and adapted selected health education resources into Ojibway, Oji-Cree, Punjabi, Hindi, Mandarin, and Cantonese, among other languages, to help patients from diverse populations learn about the risk factors and warning signs of a heart attack.

Question 11

A 32-year-old woman tells the nurse that she has noticed "very sudden, jerky movements" mainly in her hands and arms.She says, "They seem to come and go, primarily when I am trying to do something.I haven't noticed them when I'm sleeping." This description suggests:

Accepted Answer

The sudden, jerky movements that come and go and are primarily seen during voluntary movements point towards chorea. Tics are repetitive, stereotyped, and purposeless movements or vocalizations that are more common in childhood. Athetosis is slow, writhing movements that tend to be more prominent in the distal extremities. Myoclonus is rapid, shock-like muscle contractions that can occur in various body parts, but are not typically associated with voluntary movements.

Question 12

During an assessment of a 62-year-old man, the nurse notices that the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements.These findings would be consistent with:

Accepted Answer

The symptoms described are classic signs of Parkinsonism, which is a degenerative disorder of the nervous system that affects movement. Stooped posture, shuffling gait, flat facial expression, and pill-rolling tremors are all characteristic of Parkinson's disease.

Question 13

A multiple sclerosis patient is unable to perform rapid alternating movements, such as rapid patting of her knees.The nurse should document this inability as:

Accepted Answer

Slow clumsy movements and the inability to perform rapid alternating movements occur with cerebellar disease.The condition is termed dysdiadochokinesia.Multiple sclerosis has cerebellar manifestations.Ataxia is an uncoordinated or unsteady gait.Astereognosis is the inability to identify an object by feeling it.Kinesthesia is the person's ability to perceive passive movement of the extremities or the loss of position sense.

Question 14

A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination; he said he fell and hit his head.During the examination, the nurse asks him to use his index finger to touch the nurse's finger, then his own nose, and then the nurse's finger again (which has been moved to a different location).The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger.The nurse should suspect which of the following?

Accepted Answer

During the finger-to-finger test, if the person has clumsy movement with overshooting the mark, either a cerebellar disorder or acute alcohol intoxication should be suspected.The person's movements should be smooth and accurate.The other options are not correct.

Question 15

The nurse is assessing the neurological status of a patient who has a late-stage brain tumour.With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot.In response, the patient's toes fan out, and the big toe shows dorsiflexion.The nurse interprets this result as:

Accepted Answer

Dorsiflexion of the big toe and fanning of all toes is a positive Babinski sign, also called up-going toes.This response occurs with upper motor neuron disease of the corticospinal (or pyramidal) tract and is an abnormal finding for adults.

Question 16

During an assessment of a 22-year-old woman who sustained a head injury from a motor vehicle accident 4 hours earlier, the nurse notices the following changes: pupils were equal, but now the right pupil is fully dilated and nonreactive; and the left pupil is 4 mm and reacts to light.What do these findings suggest?

Accepted Answer

In a person with a brain injury, a sudden, unilateral, dilated, and nonreactive pupil is ominous.Cranial nerve III runs parallel to the brainstem.When increasing intracranial pressure pushes down the brainstem (uncal herniation), it puts pressure on Cranial nerve III, causing pupil dilation.The other responses are incorrect.

Question 17

A 78-year-old man has a history of a cerebrovascular accident.The nurse notes that when he walks, his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder.His left leg is stiff and extended, and he drags the toe in a semicircle with each step.What type of gait disturbance is this individual experiencing?

Accepted Answer

The description of the left arm being immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder and the left leg being stiff and extended and dragging the toe in a semicircle with each step is consistent with spastic hemiparesis, a type of gait disturbance commonly seen after a cerebrovascular accident. Scissors gait is seen in individuals with cerebral palsy, cerebellar ataxia presents with uncoordinated and wide-based gait, and Parkinsonian gait is characterized by a shuffling gait with reduced arm swing and festination.

Question 18

In a person with an upper motor neuron lesion after a cerebrovascular accident, which of these physical assessment findings should the nurse expect?

Accepted Answer

Upper motor neuron lesions typically result in hyper-reflexia due to disruption in the inhibitory pathway from the brain to the reflex arc. Fasciculations, loss of muscle tone and flaccidity, and atrophy and wasting of muscles are all more commonly associated with lower motor neuron lesions.

Quiz 25: Neurological System