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

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.)

A)Reflexes
B)Eye response
C)Verbal response
D)Motor movement
E)Breathing pattern

Answer 1

Reflexes
Eye response
Motor movement
Breathing pattern

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)?

A)"I am more comfortable in slip-on shoes."
B)"I am no longer able to carry heavy objects."
C)"I can barely lift my arms above my shoulders."
D)"I try to only go up and down the stairs once a day."

Answer 2

"I can barely lift my arms above my shoulders."

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?

A)Administer prescribed sedation prior to testing.
B)Reassure sensations are not caused by incontinence.
C)Monitor closely for symptoms of allergic reactions.
D)Provide pain medication as soon as the test is done.

Answer 3

Provide pain medication as soon as the test is done.

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?

A)The great toe extends and the other toes fan out.
B)All the toes curl toward the sole of the foot.
C)The great toe flexes when sole is stroked.
D)The foot is jerked away when the sole is stroked.

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?

A)Instruct the family that the same practice should be continued at home.
B)Share that the practice keeps the patient ready for ambulating to the bathroom.
C)Explain that this practice keeps the sheets from placing pressure on the feet.
D)Explain that without the proper foot position, it is impossible to stand.

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?

A)Normal loss of neurons related to aging
B)Early manifestation of dementia
C)Normal delay in problem solving
D)Result of malnutrition and depression

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?

A)Damage to the area of the brainstem
B)Injury to the spinal cord and ascending nerves
C)Significant impairment of cerebral functioning
D)Likelihood of coma preceding brain death

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.)

A)Check blood urea nitrogen (BUN) and creatinine levels.
B)Question the patient about allergies to dye, shellfish, or iodine.
C)Determine if the patient has aneurysm clips or metal pins in the body.
D)Explain to the patient that a sensation of warmth may be felt when the dye is injected.
E)Tell the patient to report any nausea, itchiness, or difficulty breathing during the scan.

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?

A)Electroencephalogram
B)Angiogram
C)Myelogram
D)Spinal x-rays

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?

A)Venereal disease research laboratory test (VDRL)
B)Anticholinesterase testing with antibody titers
C)Liver function and renal function tests
D)Erythrocyte sedimentation rate (ESR) and white blood cell (WBC) count

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?

A)The test is positive and indicates an inner ear infection.
B)The test is negative and indicates a benign cerebral tumor.
C)The test is positive and indicates cerebellar dysfunction.
D)The test is negative and indicates cochlear 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?

A)Place the patient's call light within reach.
B)Ask the patient if the new position is comfortable.
C)Check that her breast is not compressed under her body.
D)Massage reddened or blanched areas on her back.

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?

A)The patient is likely to also have a cognitive deficit.
B)The patient will be able to answer yes-or-no questions.
C)A picture board will help the patient with word searching.
D)Profanity is expected due to patient frustration.

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?

A)Provide high-protein, high-caloric foods and supplements.
B)Position the patient to sit upright as much as possible.
C)Plan for small frequent meals to improve toleration.
D)Allow the patient adequate time and privacy to self-feed.

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.)

A)Spinal cord
B)Femoral nerve
C)Anterior fibula muscle
D)Posterior tibial muscle
E)Quadriceps femoris muscle

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?

A)Verbal commands are completed as stated.
B)The patient arouses quickly from a state of drowsiness.
C)The patient falls asleep in the middle of a sentence.
D)The patient withdraws from mild pain stimulation.

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)?

A)The patient admitted with dysphagia who choked on a thickened liquid
B)The patient who begins to exhibit lack of coordination and aphasia
C)The patient whose neurologic checks show slight variations over 8 hours
D)The patient who reports tingling in the fingers 1 hour after surgery on the hand

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.)

A)Pons
B)Medulla
C)Thalamus
D)Brainstem
E)Hypothalamus

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.)

A)Relaxation of bladder
B)Decrease in peristalsis
C)Dilation of bronchioles
D)Decrease in heart rate to normal
E)Increase in salivary gland secretion

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?

A)Clean gloves
B)Reflex hammer
C)Cotton ball
D)Pointed object