Deck 41: Assessing the Nervous System

Question 1

The nurse recognizes normal cerebral spinal fluid (CSF) as

A)yellow without sediment.
B)blood tinged without sediment.
C)clear and colorless.
D)pink without sediment.

Answer 1

clear and colorless.

Question 2

The patient has lower motor neuron injuries. The nurse realizes that what type of reflexes are present?

A)decreased
B)increased
C)normal
D)exaggerated

Answer 2

decreased

Question 3

When assessing cognitive function, the nurse should evaluate the patient's

A)ability to smell items placed under the nose while eyes are closed.
B)orientation to time, place, person, and ability to recall recent and past events.
C)ability to walk with a smooth, steady gait.
D)level of consciousness.

Answer 3

orientation to time, place, person, and ability to recall recent and past events.

Question 4

When the patient is supine and the head is flexed to the chest without pain, resistance, or flexion of the hips or knees, the nurse is observing

A)Doll's eyes sign.
B)Brudzinski's sign.
C)Babinski's sign.
D)Kernig's sign.

Question 5

Normally a patient can differentiate between soft and sharp and can feel vibrations accurately. To test sensory function the nurse should do which of the following?

A)Touch both sides of various parts of the body with a sharp and a dull object.
B)Have the patient distinguish which parts of the body are being touched.
C)Ask the patient to guess whether he or she is being touched with a paper clip or a needle.
D)Touch a part of the body without the patient looking and have him or her identify the area being touched.

Question 6

The nurse describes Alzheimer's disease (AD) to a civic group as which of the following? Select all that apply.

A)increases in incidence with age
B)tends to run in families
C)more common in men
D)caused by a virus
E)caused by environmental contaminants

Question 7

While performing the Romberg test, the nurse asks the patient to stand with his or her feet together and eyes closed. What must the nurse observe for the test to be considered normal?

A)swaying side to side
B)minimal swaying for up to 20 seconds
C)balance sufficient to hold completely still without swaying
D)swaying to one side and the loss of balance

Question 8

A patient is seen in the clinic for a neuromuscular diagnosis. What neurological test(s) help to diagnose such a disease?

A)single-photon emission computed tomography (SPECT)
B)positron emission tomography (PET)
C)magnetic resonance imaging (MRI)
D)electromyogram (EMG)

Question 9

When testing the patient to determine if tremors are present, the nurse should assess for which of the following?

A)shaking
B)jerky movements
C)rhythmic movements
D)fasciculations

Question 10

When testing cranial nerve XI (spinal accessory), the nurse should ask the patient to do which of the following?

A)Shrug shoulders and turn head against resistance.
B)Stick out the tongue and move it from side to side.
C)Taste foods and distinguish sweet from sour.
D)Smell and identify correctly with one side of the nares blocked.

Question 11

When the nurse is assessing the functional health pattern of health perception-health management for a patient with a neurological problem, which of the following Select all that apply.

A)"Have you noticed any problems with chewing?"
B)"Where were you born and raised as a child?"
C)"Has there been any change in your pattern of urinary or bowel elimination?"
D)"Do you have any problems with balance, coordination, or walking?"
E)"Would you say you think clearly?"

Question 12

One of the most common neurological diseases is characterized by abnormal cell firing in the brain. What does this disease cause in patients?

A)loss of consciousness
B)seizures
C)decerebrate posturing
D)headache

Question 13

The nurse observes a patient who has a lack of coordination, clumsy movements, and an unbalanced gait. What term describes these observations?

A)flaccidity
B)paralysis
C)hemiparesis
D)ataxia

Question 14

When the nurse asks the patient to walk heel-to-toe, on toes, and then on heels, what function is being checked?

A)cerebellar
B)cerebral
C)midbrain
D)brainstem

Question 15

A patient is brought to the emergency department by the rescue squad. The patient was thrown from a vehicle. There was questionable consciousness on the way to the hospital. What neurological tests does the nurse expect to see ordered?

A)magnetic resonance imaging (MRI) and computed tomography (CT)
B)computed tomography (CT) and positron emission tomography (PET)
C)x-rays of the skull and spine and computed tomography (CT)
D)computed tomography (CT)

Question 16

The nurse understands that age-related changes in the neurological system include a decreased number of brain cells, decreased cerebral blood flow, and decreased metabolism. An example of how this would affect home care for an older adult is which of the following? Select all that apply.

A)The older adult will be distracted after a few minutes on the task.
B)The older adult will not be open to learning to do his or her own dressing change.
C)The older adult will be less reliable to complete self-care activities.
D)When too many stimuli are present, the older adult cannot process and answer in a timely fashion.
E)Patient is at increased risk for falls.

Question 17

When the nurse is assessing muscle strength and movement, it is important to do which of the following?

A)Grade the posterior tibial pulses.
B)Grade flaccidity.
C)Observe to see whether strength and movement are bilaterally equal and strong.
D)Ask the patient to walk normally in a heel-to-toe sequence.

Question 18

A patient is in the hospital with suspected intracerebral hemorrhage. The nurse realizes that the patient will most likely have which neurological test ordered?

A)x-rays of the spine
B)computed tomography (CT)
C)evoked potentials
D)electroencephalogram (EEG)

Question 19

Abnormal posturing in adults with a neurological problem includes which of the following? Select all that apply.

A)decorticate.
B)decerebrate
C)circumduction
D)festinating
E)nystagmus

Question 20

A patient in the hospital critical care unit is being evaluated for brain death. What neurological test(s) help to determine brain death?

A)electroencephalogram (EEG)
B)computed tomography (CT)
C)evoked potentials
D)electromyogram (EMG)

Question 21

An emergency department (ED) nurse receives a report that an incoming patient has a Glasgow Coma Scale (GCS) score of 8. Which is the most appropriate action by the nurse?

A)Treat the patient's pain.
B)Assess the patient's airway, breathing, and circulation.
C)Obtain a complete history from the patient.
D)Triage the patient with the other ED patients.

Question 22

A patient experiencing extreme emotional stress is observed to be exhibiting both tachycardia and tachypnea. Which component of the patient's nervous system is responsible for normalizing the patient's response?

A)central
B)peripheral
C)sympathetic
D)parasympathetic

Question 23

The nurse observes signs that a patient may be experiencing dysfunction related to the Acoustic Nerve (CN VIII). Which action by the nurse is most appropriate for minimizing the patient's risk for injury? Select all that apply.

A)Identify the patient's fall risk category.
B)Assess the patient's gag reflex prior to offering food or liquids.
C)Assist patient with bedside sitting or toileting.
D)Assess the patient's vision using a Snellen chart.
E)Place a red "falls risk" bracelet on the patient's arm.

Question 24

Place the "X" on the position likely to occur from lesions in the corticospinal tracts.

Question 25

Which is the most appropriate question for the nurse to ask when interviewing a patient suspected of exhibiting signs of Parkinson's disease?

A)"Do you recall if any of your relatives had difficulty holding on to things with their hands?"
B)"Do you remember what you ate for breakfast this morning?"
C)"Is it painful to flex your chin to your chest?"
D)"Did your muscle weakness first occur in your arms or in your legs?"

Question 26

Which neurologic assessment is being performed in the exhibit?

A)Kernig's sign
B)Babinski reflex
C)Brudzinski's sign
D)decorticate posturing

Question 27

The nurse reads that a patient's reflexes are 3+. How does the nurse interpret this scale?

A)The reflexes are weaker than normal.
B)The reflexes are normal.
C)The reflexes are stronger than normal.
D)The reflexes are hyperactive.

Question 28

Which question by the nurse during a health history best focuses on function of the central nervous system (CNS)?

A)"Do you get dizzy when moving from a sitting to standing position?"
B)"Do you have difficulty adjusting to a change in temperature?"
C)"Do you have difficulty falling asleep in the evening?"
D)"Have you had any weight loss?"

Question 29

Which response by the nurse is appropriate for a patient who reports hearing noises when alone in a quiet room?

A)Make sure the patient is referred to a psychiatrist.
B)Document that the patient has a mental illness.
C)Ask the patient if there are any visual disturbances.
D)Explain to the patient that this is not unusual.

Question 30

Place an "X" on the test the nurse performs to test for graphesthesia.

Question 31

The nurse has just finished providing a patient's son with an explanation of the function of the Mini-Mental Status Examination (MMSE). Which statement by the patient's son indicates his understanding to the nurse?

A)"This test will evaluate my dad's ability to think, reason, and make decisions."
B)"This test will give us a good idea if dad is mentally healthy enough to live alone."
C)"If dad passes this test, we will know that his mind is still okay."
D)"I'm sure dad will do well on the test; he's always been smart."

Question 32

The nurse is expected to assess a patient for the presence of pathological reflexes. Which of the following reflexes should the nurse plan to assess? Select all that apply.

A)Babinski
B)grasp
C)snout
D)sucking
E)Achilles

Question 33

Mark the area of the brain responsible for controlling cardiac rate, blood pressure, respiration, and swallowing. [Insert Figure 41-2, remove all labels]

Question 34

When bringing in the meal tray for a patient with damage to the glossopharyngeal nerve (CN IX), which action by the nurse is most appropriate?

A)Tell the patient what food is on the tray.
B)Assess the patient's ability to swallow.
C)Speak loudly and make eye contact with the patient.
D)Assist the patient in identifying where items are on the tray.

Question 35

The nurse is assessing the patient using the technique shown. What is considered a normal finding using this technique?

A)pain only at the hip during flexion
B)resistance in the hip joint
C)a clicking sound in the knee upon flexion
D)no pain or resistance in either joint

Question 36

The patient sustained a head injury in a fall and now is having problems seeing. Place the X on the area of the brain where the nurse suspects this patient has been injured.

Question 37

A patient's family asks the nurse, "What does damage to Broca's area mean?" after the healthcare provider leaves the patient's room. Which is the best response by the nurse?

A)"The way you communicate will have to change."
B)"You'll have to speak very loudly when you talk."
C)"Make sure there are no obstacles in the room, because sight will be a problem."
D)"Perhaps you would like to learn how to provide range-of-motion exercises."

Question 38

While assessing an unconscious patient's neurological status, the nurse applies pain by pinching the sternocleidomastoid muscle. Which statement by the nurse indicates an understanding of the use of this technique?

A)"Pain will make abnormal motor responses observable."
B)"An unconscious patient's pain threshold is abnormally high."
C)"Response to pain is an indicator of cognitive function."
D)"The patient is most likely to respond to pain at that site."

Question 39

During an assessment of a patient's cranial nerves, the nurse states, "Please stick out your tongue." The nurse observes that the tongue deviates markedly to the right side. Which is the patient most likely exhibiting?

A)an abnormal hypoglossal nerve response
B)first cranial nerve (CN I) damage
C)a sluggish oculomotor response
D)absence of the Homans' sign

Question 40

Place the "X" on the picture that represents testing of the brachioradialis reflex.

Question 41

During the health assessment interview, the nurse notices the patient has a fine tremor in the right hand and arm. The patient says, "They tell me this is a primary essential tremor. What does that mean?" What is the best response by the nurse?

A)"Essential tremors occur 5 to 10 years before the onset of Parkinson's disease."
B)"When essential tremors are a primary disorder, they are usually inherited."
C)"Essential tremors are very rare, only about 100,000 people have them."
D)"People with essential tremors often go on to develop cardiovascular disease."

Question 42

The patient is brought to the emergency department following a motor vehicle accident. The patient jerks away from the nurse attempting to start an IV in the right arm and says, "Bring me my book. I need to eat." When asked what happened in the accident, the patient looks frantically from nurse to nurse and says, "I have a dog." Calculate the patient's Glasgow Coma score.

Question 43

The nurse asks the patient who has suffered a cerebral vascular accident (CVA) to complete the heel-to-shin test. What is being tested with this technique?

A)ataxia
B)graphesthesia
C)coordination
D)spasticity