Question 1

The nurse is using the FOUR tool to assess a patient's neurologic functioning. In which areas does the nurse collect data when using this tool? (Select all that apply.)

Accepted Answer

A,B,D,E

Question 2

The nurse is collecting data from a patient in the HCP's office. Which statement by the patient indicates that the patient is likely to be having problems with some activities of daily living (ADLs)?

Accepted Answer

Difficulty lifting arms above shoulders can indicate problems with ADLs like dressing or grooming, which require arm mobility.

Question 3

The nurse will be accompanying a patient to the radiology department for the performance of a computerized axial tomography (CAT) scan with contrast. The patient is an older adult who has pain and exhibits signs of mild agitation. Which nursing care for the patient related to the examination is inappropriate?

Accepted Answer

Administering pain medication immediately after the test may not be appropriate without first assessing the patient's pain level and potential side effects of the contrast medium used during the CAT scan. Pain management should be tailored to the patient's current condition and needs, which can only be accurately determined after the test and any immediate effects of the contrast medium have been evaluated.

Question 4

The nurse is monitoring a patient who is 4 years of age who fell down a flight of steps. A Babinski response was not present during the initial assessment. The RN asks the nurse to recheck for a Babinski reflex and report abnormal responses. Which response will the nurse report to the RN?

Accepted Answer

The Babinski reflex is considered normal in infants but should disappear by the age of 2 years. In older children and adults, a positive Babinski sign (where the great toe extends and the other toes fan out) is abnormal and may indicate neurological damage.

Question 5

An older adult patient is hospitalized for a respiratory infection. The nurses have been placing the patient's feet into high-top tennis shoes even while in bed. Which answer does the nurse make to a family member who asks about the purpose of the shoes?

Accepted Answer

The answer of An older adult patient is hospitalized for...

Question 6

The nurse asks an older adult patient to count backward from 100 in increments of three; the patient counts correctly until the nurse stops the process. Which reason does the nurse identify as a likely cause of long periods of hesitation during the process?

Accepted Answer

The answer of The nurse asks an older adult patient...

Question 7

The nurse is assisting with a patient who was injured in an accident and experienced head injury. The RN records the patient as exhibiting decerebrate posturing. Which condition does the nurse associate with the RN's finding?

Accepted Answer

Decerebrate posturing is associated with damage to the brainstem, which is responsible for basic life functions and reflexes.

Question 8

The nurse is caring for a patient scheduled for a computed tomography (CT) scan with contrast. Which actions does the nurse include in the preprocedure preparation? (Select all that apply.)

Accepted Answer

These actions are important for ensuring the patient's safety and comfort during a CT scan with contrast. Checking BUN and creatinine levels helps assess kidney function, which is crucial since the contrast can affect the kidneys. Questioning the patient about allergies to dye, shellfish, or iodine is important because the contrast material may cause allergic reactions in sensitive individuals. Explaining the sensation of warmth helps prepare the patient for what to expect, reducing anxiety. Telling the patient to report any adverse reactions like nausea, itchiness, or difficulty breathing during the scan is vital for immediate intervention if an allergic reaction occurs. Option C is not relevant to CT scan preparation as it pertains more to magnetic resonance imaging (MRI) safety.

Question 9

The nurse is preparing a patient for neurologic testing. Which testing does the nurse expect if the patient expresses severe pain in the lower back aggravated by movement?

Accepted Answer

A myelogram is a diagnostic imaging test used to identify issues with the spinal cord, nerve roots, and other tissues, which is appropriate for severe lower back pain aggravated by movement.

Question 10

A patient comes to the emergency room exhibiting confusion and manifestations related to dementia. Records from previous visits indicate a history of drug and alcohol abuse along with frequent treatment for sexually transmitted infections (STIs). Which laboratory test does the nurse consider to be unnecessary?

Accepted Answer

Anticholinesterase testing with antibody titers is primarily used to diagnose and monitor autoimmune disorders like myasthenia gravis, which are unrelated to the symptoms of confusion, dementia, drug and alcohol abuse, or STIs indicated in the patient's history.

Question 11

The nurse is preparing to perform a Romberg test on a client. The nurse instructs the patient to stand with the feet together and eyes closed. After 20 seconds, the patient leans to one side and exhibits a swaying motion. Which conclusion does the nurse draw from these test results?

Accepted Answer

The Romberg test is used to assess cerebellar function. A positive test, as seen in this case, indicates cerebellar dysfunction.

Question 12

The nurse is providing care for a female patient who is paralyzed from a C-4 spinal cord injury. The patient is turned and repositioned every 2 hours. Which action does the nurse take when repositioning the patient in a side-lying position?

Accepted Answer

Checking that the patient's breast is not compressed under her body is an important step when repositioning a patient in a side-lying position to prevent skin breakdown and discomfort.

Question 13

A patient is being admitted to a long-term care facility. Medical history includes a recent stroke with dysarthria. Which factor does the nurse consider when providing care for this patient?

Accepted Answer

The answer of A patient is being admitted to a...

Question 14

The nurse is providing care for a patient who is experiencing difficulty eating due to a neurologic dysfunction. Which action by the nurse will be least helpful in promoting adequate nutritional intake for this patient?

Accepted Answer

Allowing the patient adequate time and privacy to self-feed might be less helpful if the patient's neurologic dysfunction significantly impairs their ability to eat independently. Assistance or supervision might be necessary to ensure safety and adequate intake.

Question 15

While observing the neurologist complete a neurologic examination, the nurse notes that a patient has an absent left patellar reflex. Which possible areas of dysfunction does the nurse consider? (Select all that apply.)

Accepted Answer

The patellar reflex, also known as the knee-jerk reflex, is mediated by the L2-L4 spinal nerve roots, involves the femoral nerve, and tests the function of the quadriceps femoris muscle. An absent patellar reflex could indicate dysfunction in any of these areas: the spinal cord (at the level of the lumbar vertebrae involved in the reflex arc), the femoral nerve (which innervates the quadriceps femoris muscle), or the quadriceps femoris muscle itself (which is responsible for extending the knee and is the effector muscle in the patellar reflex). The anterior fibula muscle and posterior tibial muscle are not directly involved in the patellar reflex.

Question 16

The nurse is assisting with the care of a patient admitted following a fall resulting in a head injury. Which finding prompts the nurse to inform the RN that the patient is experiencing a negative change in the level of consciousness?

Accepted Answer

Falling asleep in the middle of a sentence indicates a change in the level of consciousness, suggesting that the patient may be experiencing increased drowsiness or an inability to maintain alertness, which is concerning following a head injury.

Question 17

The nurse is providing care for multiple patients. Which patient does the nurse decide to report immediately to the health care provider (HCP) or the registered nurse (RN)?

Accepted Answer

The patient beginning to exhibit lack of coordination and aphasia may be experiencing a stroke or significant neurological change, requiring immediate attention and intervention by a health care provider or registered nurse.

Question 18

The nurse is preparing a review of the neurologic system as part of a community health presentation. Which structures does the nurse identify as being part of the diencephalon? (Select all that apply.)

Accepted Answer

The diencephalon is a part of the brain that includes the thalamus and the hypothalamus. The thalamus acts as a relay station for sensory and motor signals to the cerebral cortex, while the hypothalamus is involved in various functions such as temperature regulation, hunger, thirst, and emotional activity. The pons and medulla are parts of the brainstem, not the diencephalon, and the brainstem itself is a separate structure that includes the midbrain, pons, and medulla.

Question 19

The nurse suspects a patient is experiencing a sympathetic response. Which manifestations does the nurse expect the patient to exhibit? (Select all that apply.)

Accepted Answer

The sympathetic nervous system is responsible for the "fight or flight" response, which includes relaxation of the bladder (A), decrease in peristalsis (B), and dilation of bronchioles (C) to prepare the body for rapid action.

Question 20

The nurse is preparing to collect data during the reassessment of a patient's neurologic status. Which equipment is unnecessary for this procedure?

Accepted Answer

The answer of The nurse is preparing to collect data...

Quiz 47: Neurologic System Function, Assessment, and Therapeutic Measures