Question 1

The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which of the following structures?

Accepted Answer

The cerebral cortex is responsible for thought,memory,reasoning,sensation,and voluntary movement.

Question 2

During the assessment of an 80-year-old patient,the nurse notes that his hands show tremors when he reaches for something and his head is always nodding.There is no associated rigidity with movement.Which of the following statements is most accurate?

Accepted Answer

Senile tremors occasionally occur.These benign tremors include an intention tremor of the hands,head nodding (as if saying yes or no),and tongue protrusion.

Question 3

Which of the following would the nurse use to test the motor coordination of an 11-month old infant?

Accepted Answer

To screen gross and fine motor coordination,use the Denver II with its age-specific developmental milestones.

Question 4

A patient is not able to perform rapid alternating movements such as patting her knees rapidly.The nurse would document this as:

Accepted Answer

Slow clumsy movements and the inability to perform rapid alternating movements occur with cerebellar disease.The condition is termed dysdiadochokinesia.

Question 5

The nurse is caring for a patient who has just had neurosurgery.To assess for increased intracranial pressure,what would the nurse include in the assessment?

Accepted Answer

Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process.These people must be monitored closely for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure.Use an abbreviation of the neurologic examination in the following sequence: level of consciousness,motor function,pupillary response,and vital signs.

Question 6

In a person with an upper motor neuron lesion such as a cerebrovascular accident,which of the following physical assessment findings would the nurse expect to see?

Accepted Answer

Hyperreflexia,diminished or absent superficial reflexes,increased muscle tone or spasticity can be expected with upper motor neuron lesions.

Question 7

During an examination,the nurse notes severe nystagmus in both eyes of a patient.Which of the following conclusions is correct?

Accepted Answer

End-point nystagmus at an extreme lateral gaze occurs normally.Assess any other nystagmus carefully.Severe nystagmus occurs with disease of the vestibular system,cerebellum,or brainstem.

Question 8

When the nurse is testing the triceps reflex,what is the expected response?

Accepted Answer

The normal response is extension of the forearm.

Question 9

A 32-year-old woman tells the nurse that she has noticed "very sudden,jerky movements" mainly in her hands and arms."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

Chorea is characterized by sudden,rapid,jerky,purposeless movements that involve the limbs,trunk,or face.Chorea occurs at irregular intervals,and the movements are all accentuated by voluntary actions.

Question 10

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

Accepted Answer

With a herniated intervertebral disk or lower motor neuron lesion,there is loss of tone,flaccidity,atrophy,fasciculations,and hyporeflexia or areflexia.

Question 11

In assessing a 70-year-old patient who has had a recent cerebrovascular accident,the nurse notes right-sided weakness.What might the nurse expect to find when testing his reflexes on the right side?

Accepted Answer

Hyperreflexia is the exaggerated reflex seen when the monosynaptic reflex arc is released from the influence of higher cortical levels.This occurs with upper motor neuron lesions (e.g. ,a cerebrovascular accident).

Question 12

The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination.When striking the Achilles and quadriceps,the nurse is unable to elicit a reflex.The nurse's next response should be to:

Accepted Answer

Sometimes the reflex response fails to appear.Try further encouragement of relaxation,varying the person's position or increasing the strength of the blow.Reinforcement is another technique to relax the muscles and enhance the response.Ask the person to perform an isometric exercise in a muscle group somewhat away from the one being tested.For example,to enhance a patellar reflex,ask the person to lock the fingers together and "pull."

Question 13

During an assessment of a 62-year-old man the nurse notes the following: stooped posture;walks with shuffling,short steps;very rigid;flat facial expression;fingers move as if rolling a pill with them.These findings would be consistent with:

Accepted Answer

The stooped posture,shuffling walk,short steps,flat facial expression,and pill-rolling finger movements are all found in parkinsonism.

Question 14

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 circumducts with each step.What type of gait disturbance is this individual experiencing?

Accepted Answer

With spastic hemiparesis,the arm is immobile against the body.There is flexion of the shoulder,elbow,wrist,and fingers and adduction of the shoulder.The leg is stiff and extended and circumducts with each step.Causes of this type of gait include cerebrovascular accident.

Question 15

To assess the head control of a 4-month-old infant,the nurse lifts the infant up in a prone position while supporting his chest.The nurse looks for what normal response?

Accepted Answer

At 3 months of age,the baby raises the head and arches the back as if in a swan dive.This is the Landau reflex,which persists until 1¹/₂ years of age.

Question 16

The nurse is testing superficial reflexes on an adult patient.When stroking up the lateral side of the sole and across the ball of the foot,the nurse notices the plantar flexion of the toes.How would the nurse document this finding?

Accepted Answer

With the same instrument,draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot,like an upside-down "J." The normal response is plantar flexion of the toes and sometimes of the whole foot.

Question 17

During an assessment of a 32-year-old patient with a recent head injury,the nurse notes that the patient responds to pain by extending,adducting,and internally rotating his arms.His palms pronate and his lower extremities extend as well with plantar flexion.Which of the following statements about these findings is accurate?

Accepted Answer

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

Question 18

While assessing a 7-month-old infant,the nurse makes a loud noise and notes the following response: abduction and flexion of arms and legs;fanning of fingers,and curling of index and thumb in C position followed by infant bringing in arms and legs to body.What does the nurse know about this response?

Accepted Answer

The Moro reflex is present at birth and disappears at 1 to 4 months.Absence of the Moro reflex in the newborn or persistence after 5 months of age indicates severe central nervous system injury.

Question 19

In the assessment of a 1-month-old infant,the nurse notes a lack of response to noise or stimulation.The mother reports that in the last week he has been sleeping all the time and when awake all he does is cry.The nurse hears that the infant's cries are very high pitched and shrill.What would be the nurse's appropriate response to these findings?

Accepted Answer

A high-pitched shrill cry or cat-sounding screech occurs with central nervous system damage.Lethargy,hyporeactivity,hyperirritability,and parent's report of significant change in behavior all warrant referral.

Question 20

During an assessment of a 22-year-old woman who has a head injury from a car accident 4 hours ago,the nurse notes the following change: pupils were equal,but now the right is fully dilated and nonreactive,left is 4 mm and reacts to light.What would finding this suggest?

Accepted Answer

In a brain-injured person,a sudden,unilateral,dilated,and nonreactive pupil is ominous.Cranial nerve III runs parallel to the brain stem.When increasing intracranial pressure pushes the brainstem down (uncal herniation),it puts pressure on cranial nerve III,causing pupil dilation.

Quiz 23: Neurologic System