Question 1

Which finding would the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion?

Accepted Answer

Because the cell bodies of lower motor neurons are located in the spinal cord,damage to the neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor neuron lesions.

Question 2

Propranolol (Inderal),a b-adrenergic blocker that inhibits sympathetic nervous system activity,is prescribed for a patient who has extreme anxiety about public speaking. The nurse monitors the patient for

Accepted Answer

Inhibition of the fight-or-flight response leads to a decreased heart rate. Dry mouth,constipation,and urinary retention are associated with peripheral nervous system blockade.

Question 3

The nurse will anticipate teaching a patient with a possible seizure disorder about which test?

Accepted Answer

Seizure disorders are usually assessed using EEG testing. Evoked potential is used to diagnose problems with the visual or auditory systems. Cerebral angiography is used to diagnose vascular problems. EMG is used to evaluate electrical innervation to skeletal muscle.

Question 4

Which problem can the nurse expect for a patient who has a positive Romberg test result?

Accepted Answer

A positive Romberg test result indicates that the patient has difficulty maintaining balance when standing with the eyes closed. The Romberg does not test for orientation,thermoregulation,or discomfort.

Question 5

The charge nurse is observing a new staff nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action indicates a need for further teaching of the new nurse about neurologic assessment?

Accepted Answer

When performing a sensory assessment,the nurse should not provide verbal clues. The other actions by the new nurse are appropriate.

Question 6

Which information about a 76-yr-old patient should the nurse report as uncharacteristic of normal aging?

Accepted Answer

Although changes in appetite are normal with aging,a 15-lb weight loss requires further investigation. Orthostatic drops in blood pressure,changes in sleep patterns,and slowing of reflexes are normal changes in aging.

Question 7

The priority nursing assessment for a patient being admitted with a brainstem infarction is

Accepted Answer

Vital centers that control respiration are located in the medulla and part of the brainstem,and will require priority assessments because changes in respiratory function may be life threatening. The other information will also be obtained by the nurse but is not as urgent.

Question 8

When admitting an acutely confused patient with a head injury,which action should the nurse take?

Accepted Answer

When admitting a patient who is likely to be a poor historian,the nurse should obtain health history information from others who have knowledge about the patient's health. Waiting until the patient is oriented or obtaining only physiologic data will result in incomplete assessment data,which could adversely affect decision making about treatment. Asking leading questions may result in inaccurate or incomplete information.

Question 9

During the neurologic assessment,the patient is unable to respond verbally to the nurse but cooperates with the nurse's directions to move his hands and feet. The nurse will suspect

Accepted Answer

Expressive speech (ability to express the self in language)is controlled by Broca's area in the frontal lobe. The temporal lobe contains Wernicke's area,which is responsible for receptive speech (ability to understand language input). The cerebellum and brainstem do not affect higher cognitive functions such as speech.

Question 10

Which equipment will the nurse obtain to assess vibration sense in a patient with diabetes who has peripheral nerve dysfunction?

Accepted Answer

Vibration sense is testing by touching the patient with a vibrating tuning fork. The other equipment is needed for testing of pain sensation,reflexes,and two-point discrimination.

Question 11

Several patients have been hospitalized for diagnosis of neurologic problems. Which patient will the nurse assess first?

Accepted Answer

Because cerebral angiograms require insertion of a catheter into the femoral artery,bleeding is a possible complication. The nurse will need to check the pulse,blood pressure,and the catheter insertion site in the groin as soon as the patient arrives. Carotid duplex studies and EEG are noninvasive. The nurse will need to assist with the lumbar puncture as soon as possible,but monitoring for hemorrhage after cerebral angiogram has a higher priority.

Question 12

A 39-yr-old patient with a suspected herniated intervertebral disc is scheduled for a myelogram. Which information communicated by the nurse to the health care provider before the procedure would change the procedural plans?

Accepted Answer

A contrast medium containing iodine is injected into the subarachnoid space during a myelogram. The patient's allergy would contraindicate the use of this medium. The health care provider may need to modify the orders to prevent back pain,but this can be done after the procedure. Clear liquids are usually considered safe up to 4 hours before a diagnostic or surgical procedure. The patient's anxiety should be addressed,but procedural plans would not need to be changed.

Question 13

Which action will the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX)and vagus nerve (CN X)?

Accepted Answer

The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. A patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway,but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve. Balance and coordination are cerebellar functions.

Question 14

The nurse performing a focused assessment of left posterior temporal lobe functions will assess the patient for

Accepted Answer

The posterior temporal lobe integrates the visual and auditory input for language comprehension. Reasoning and problem solving are functions of the anterior frontal lobe. Sensation on the left side of the body is located in the right postcentral gyrus. Voluntary movement on the right side is controlled in the left precentral gyrus.

Question 15

An unconscious male patient has just arrived in the emergency department with a head injury caused by a motorcycle crash. Which order should the nurse question?

Accepted Answer

After a head injury,the patient may be experiencing intracranial bleeding and increased intracranial pressure,and herniation of the brain could result if lumbar puncture is performed. The other orders are appropriate.

Question 16

A patient has a tumor in the cerebellum. The nurse will plan interventions to

Accepted Answer

Because functions of the cerebellum include coordination and balance,the patient with dysfunction is at risk for falls. The cerebellum does not affect memory,mood,or swallowing ability.

Question 17

Which cerebrospinal fluid analysis result should the nurse recognize as abnormal and communicate to the health care provider?

Accepted Answer

The protein level is high. The specific gravity,WBCs,and glucose values are normal.

Question 18

To assess the functions of the trigeminal and facial nerves (CNs V and VII),the nurse should

Accepted Answer

The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to evaluate function of the oculomotor nerve.

Question 19

Which nursing action will be included in the plan of care for a patient who has had cerebral angiography?

Accepted Answer

Because a catheter is inserted into an artery (e.g.,the femoral artery)during cerebral angiography,the nurse should assess for bleeding after this procedure that can affect pulse and blood pressure. The other nursing assessments are not needed after angiography.

Question 20

A patient with suspected meningitis is scheduled for a lumbar puncture. Before the procedure,the nurse will plan to

Accepted Answer

For a lumbar puncture,the patient lies in the lateral recumbent position. The procedure does not usually require a sedative,is done in the patient room,and has no risk for aspiration.

Quiz 55: Assessment of Nervous System