Deck 13: Assessing the Sensory-Neurologic System

Question 1

What is the best score a patient can make on the Glasgow Coma Scale?

A) 1
B) 10
C) 15
D) 25

Answer 1

15

Question 2

Which is a primary function of the sensory-neurologic system?

A) Allows interaction with the internal environment
B) Maintains activities with the external environment
C) Acts as a main circuit board of the body
D) Restores neurons that are damaged

Answer 2

Acts as a main circuit board of the body

Question 3

The nurse is assessing a preschool-age patient who is exhibiting symptoms of hyperactivity. Which question is most appropriate for the nurse to ask the patient's mother during the health history interview?

A) "Does your child consume a lot of sugar?"
B) "Did you use drugs while you were pregnant?"
C) "Did you consume enough folic acid during pregnancy?"
D) "Does your child eat a lot of vegetables?"

Answer 3

"Does your child consume a lot of sugar?"

Question 4

A patient being assessed for level of orientation is unable to state what day it is. Which question is appropriate for the nurse to ask the patient next?

A) "Do you know what the month is?"
B) "Do you know where you are?"
C) "Do you know who the President of the United States is?"
D) "Are you confused?"

Question 5

Which question may be the most helpful in identifying the cause of a headache?

A) "What were you doing before the headache began?"
B) "Do any visual changes accompany the headache?"
C) "Does anything make the headache better?"
D) "What does it feel like?"

Question 6

Of the following patients, who is most likely to need a neurologic assessment?

A) A 2-year-old, in for a well-child visit, sitting quietly the on mother's lap
B) An 8-year-old with rhinitis, coloring in a book
C) An 18-year-old car accident victim who appears sleepy
D) A 56-year-old patient with complaints of difficulty breathing

Question 7

When the patella is tapped with a reflex hammer, a patient demonstrates a sluggish response. The nurse suspects that this response may be cause by which disorder?

A) Peripheral nerve damage
B) Muscle impairment
C) Neurotransmitter deficiency
D) All of the above

Question 8

Which is an appropriate method to administer central painful stimuli to assess arousal level?

A) Nipple twist
B) Sternal rub
C) Nail pressure
D) Achilles tendon squeeze

Question 9

The nurse is assessing a preschool-age patient during a scheduled health maintenance visit. Which question is appropriate to determine whether the patient is at risk for lead poisoning?

A) "Does your child eat a balanced diet?"
B) "Does your child attend day care?"
C) "What year was your house built?"
D) "What type of child safety seat do you use?"

Question 10

Which three assessments make the Cushing triad?

A) Widening pulse pressure, bradycardia, and irregular respiratory pattern
B) Decreased pulse pressure, tachycardia, and irregular respiratory pattern
C) Confusion, aphasia, and tachycardia
D) Elevated blood pressure, bradycardia, and aphasia

Question 11

When assessing Broca's area during a physical assessment, which is the nurse assessing?

A) Voluntary movement
B) Comprehension
C) Emotional expression
D) Personality

Question 12

After a traumatic brain injury, a patient is found to be positioned with arms extended and hands clenched. Which is the term used to describe this assessment finding?

A) Spinal cord lesion
B) Frontal lobe lesion
C) Decorticate (flexor) posturing
D) Decerebrate (extensor) posturing

Question 13

Which is the correct order in which to assess level of arousal?

A) Visual, auditory, and then tactile stimuli
B) Tactile, visual, and then painful stimuli
C) Auditory, tactile, and then painful stimuli
D) Painful, visual, and then auditory stimuli

Question 14

Which may be the reason for an older adult patient to exhibit poorly applied make-up and stains on the clothing?

A) Depression
B) Poor visual acuity
C) Impaired range of motion of upper extremities
D) All of the above

Question 15

The nurse is assessing the trigeminal nerve, which is responsible for which task?

A) Moving eyes diagonally
B) Moving eyes laterally
C) Chewing and conveying sensory data from the eyes, nose, and mouth
D) Articulating with the tongue, movement of the tongue, and swallowing

Question 16

Which nutrient is recommended during pregnancy to prevent neural tube defects in the fetus?

A) Iron
B) Vitamin A
C) Vitamin C
D) Folic acid

Question 17

A hyperactive patellar knee reflex during pregnancy may be indicative of which disorder?

A) Hypoglycemia
B) Hyperglycemia
C) Galactorrhea
D) Preeclampsia

Question 18

After an injury to the back of the head, the nurse anticipates an individual might have difficulty with which item?

A) Speech
B) Spatial relationships
C) Sexual arousal
D) Memory

Question 19

A patient with a suspected stroke must take prescribed medications. How should the nurse assess the patient's gag reflex before administration of medications?

A) Offer the patient a sip of water
B) Offer the patient a bite of soft food like gelatin
C) Lightly stimulate the uvula with a tongue blade
D) All of the above

Question 20

Which is typically the last to be lost in regard to determining the patient's level of orientation?

A) Purpose
B) Place
C) Time
D) Person

Question 21

Which is an appropriate nursing action when conducting a sensory system assessment?

A) Asking the patient to open both eyes
B) Asking the patient to close the right eye
C) Asking the patient to open the left eye
D) Asking the patient to close both eyes

Question 22

The nurse asks the patient to clench the jaw. Which cranial nerve (CN) is being assessed?

A) CN I
B) CN V
C) CN VII
D) CN VIII

Question 23

To perform the Romberg test, the nurse should instruct the patient to do which task?

A) Stand with feet together and arms at side with eyes open, then closed
B) Walk on the heels, then on the toes
C) Touch thumb of one hand to each finger
D) Run heel of foot down shin of opposite leg

Question 24

An adult patient is involved in an automobile accident and brought to the emergency department (ED) with head trauma. Which question would best assess cerebral function?

A) "How would you describe your eyesight?"
B) "Can you tell me your address?"
C) "Have you noticed a change in your muscle strength?"
D) "Have you noticed a change in your coordination?"

Question 25

The nurse asks the patient to stick out the tongue. Which cranial nerve is being assessed?

A) CN IX
B) CN X
C) CN XI
D) CN XII

Question 26

To assess stereognosis, which action by the nurse is appropriate?

A) Touching two points simultaneously and have patient identify touch
B) Having patient identify familiar object by touch
C) Having patient identify number written in palm of hand
D) Moving finger and having patient identify direction of movement

Question 27

The nurse has difficulty eliciting an Achilles reflex response. What reinforcement technique may be used to enhance this response?

A) Smile
B) Dorsiflex foot
C) Plantarflex foot
D) Interlock hands

Question 28

What is the normal response for the Achilles reflex?

A) Inversion of foot
B) Dorsiflexion of foot
C) Plantarflexion of foot
D) Eversion of foot

Question 29

To assess vibratory sensation, where should the nurse place the vibrating tuning fork?

A) On a tendon
B) On a bony prominence
C) On a muscle
D) On a dermatome

Question 30

The nurse asks the patient to identify a distinct odor. Which cranial nerve (CN) is being assessed?

A) CN I
B) CN V
C) CN VII
D) CN VIII

Question 31

Which statement regarding superficial sensation is accurate?

A) If superficial sensations are intact distally, they are intact proximally.
B) If superficial sensations are intact proximally, they are intact distally.
C) Dermatomes sense superficial sensations.
D) Neurons sense superficial sensations.

Question 32

An older adult patient is admitted to the medical unit with speech disturbance and right-sided weakness. Sensory assessment is included in the neurologic evaluation. If pain sensation is intact, which other area is intact and need not be tested?

A) Two-point discrimination
B) Vibratory sensation
C) Temperature sensation
D) Kinesthetic sensation

Question 33

The nurse asks the patient to shrug the shoulders against resistance. Which cranial nerve (CN) is being assessed?

A) CN IX
B) CN X
C) CN XI
D) CN XII

Question 34

The nurse is providing care to an adult patient who is diagnosed with a degenerative cerebellar disorder. Which test would best assess the patient's balance?

A) Tandem gait walking
B) Point-to-point localization
C) Rapid alternating movements (RAM)
D) Leg coordination

Question 35

When assessing the deep tendon reflexes (DTRs), what is the normal response of the biceps reflex?

A) Elbow flexion
B) Elbow extension
C) Forearm supination
D) Hand pronation

Question 36

To assess for increasing intracranial pressure (ICP), the nurse should assess which key cranial nerves (CNs)?

A) II, III, IV, and VI
B) I, V, VII, and IX
C) V, VII, XI, and XII
D) IX, X, XI, and XII

Question 37

The nurse asks the patient to raise the eyebrows. Which cranial nerve (CN) is being assessed?

A) CN V
B) CN VII
C) CN VIII
D) CN IX