Deck 21: The Neurologic System

Question 1

Which behavior causes the nurse to report a positive Romberg test?

A) The patient cannot keep his eyes closed.
B) The patient cannot touch his nose with eyes closed.
C) The patient complains of dizziness.
D) The patient sways from side to side.

Answer 1

The patient sways from side to side.

Question 2

The nurse interprets the physician's finding of a grade of 2/5 on the Achilles tendon to mean what has occurred?

A) Hyperreflexive response for the fifth and sixth cervical nerves
B) Exaggerated response for the seventh and eighth cervical nerves
C) Normal response for the first and second sacral nerves
D) Weak response for the second through the fourth lumbar nerves

Answer 2

Normal response for the first and second sacral nerves

Question 3

The loss of neurons in the autonomic nervous system (ANS)of the older adult will cause the older adult to take longer to complete which action(s)?

A) Recuperate from an illness
B) Apply brakes to stop a car
C) Form words into sentences
D) Climb stairs
E) Learn new material

Answer 3

Recuperate from an illness
Apply brakes to stop a car

Question 4

The nurse is performing a neurologic assessment on a patient.Which action should the nurse take to adequately test the effectiveness for the hypoglossal nerve?

A) Ask the patient to touch the tip of the tongue to each cheek.
B) Check air movement through each nostril separately.
C) Ask the patient to wrinkle the forehead.
D) Ask the patient to shrug the shoulders.

Question 5

A student nurse questions the nurse about the difference between a quadriplegic and a tetraplegic patient.Which statement correctly describes tetraplegia?

A) Tetraplegic patients are capable of fewer fine motor movements.
B) Tetraplegic patients can experience pain in paralyzed parts.
C) Tetraplegic patients are more easily rehabilitated.
D) Tetraplegia is the newer term for the old term quadriplegia.

Question 6

The patient scheduled for a PET (positron emission tomography)scan of the brain asks if there is any special preparation for the test.The nurse correctly responds with which statement(s)?

A) "There is no special preparation involved with this test since it is noninvasive."
B) "You should avoid any tranquilizers or sedatives the night before and the day of the test."
C) "You will need to sign a consent form for this test to be performed."
D) "You will have two IVs inserted for the examination."
E) "You should wait to empty your bladder once the test is completed."

Question 7

The nurse is performing a neurologic assessment on a newly admitted patient with a head injury.Which sign best indicates that the patient may have experienced a brainstem injury?

A) Nystagmus
B) Decerebrate posturing
C) Seizure activity
D) Glasgow Coma Scale score of 3

Question 8

When feeding a patient with dysphagia with a left-sided hemiplegia,how should the nurse position the patient?

A) Side-lying on the right side
B) Semi-Fowler
C) High Fowler
D) Upright at a table in a wheelchair

Question 9

Bladder training begins with scheduling the patient's toileting in what time increment?

A) Every hour
B) Every 2 hours
C) Every 4 hours
D) Every 6 hours

Question 10

The nurse is assessing an 80-year-old patient.The nurse correctly attributes the slowed knee jerk reflex with which age-related change?

A) Diminished brain cells
B) Degeneration of myelin sheath
C) Weakened muscles
D) Irritation of nerve roots

Question 11

The nurse is assessing muscle strength in a fully conscious patient as part of a neurologic assessment.Which technique should the nurse employ?

A) Press down on the patient's extended arms one at a time while the patient attempts to raise the arm.
B) Apply pressure above the eye and push upward while the patient attempts to remove the hand.
C) Pinch the trapezius muscle at the angle of the shoulder and neck while twisting the fingers slightly.
D) Rub the sternum with fisted knuckles in a twisting motion while the patient attempts to remove the fist.

Question 12

Which statement(s)provide examples of ways in which individuals may be proactive in reducing neurologic injuries?

A) Refusing to start the car until all seat belts are buckled.
B) Requiring children to wear bike helmets.
C) Reminding swimmers to test water depth before diving.
D) Encouraging use of hard hats at industrial sites.
E) Discouraging recreational drug use.
F)None of above

Question 13

The nurse is caring for a patient who requires neurologic checks.When performing an assessment,how should the nurse best evaluate the patient's thinking?

A) Ask the patient to add three numbers together in his head.
B) Ask the patient to identify the name of the present month.
C) Ask the patient what he would do in the event of a fire.
D) Ask the patient what the last major holiday was.

Question 14

Which reflex indicates an abnormality in the motor control pathways from the cerebral cortex?

A) Babinski reflex
B) Biceps reflex
C) Brachioradialis reflex
D) Knee jerk reflex

Question 15

A patient is admitted to the hospital to rule out the possibility of bacterial meningitis.Which test will be most helpful in diagnosing this condition?

A) Magnetoencephalography (MEG)
B) Myelography
C) Cerebral angiography
D) Lumbar puncture for cerebrospinal fluid (CSF) analysis and culture

Question 16

While performing an assessment,the nurse taps a patient's knee and observes that the quadriceps muscle reflexively contracts.How should the nurse document this finding?

A) Patellar reflex 2/5
B) Patellar reflex 4/5
C) Achilles reflex 2/5
D) Achilles reflex 4/5

Question 17

The patient is caring for a patient who spontaneously opens his eyes,localizes pain,and carries out confused conversation.The nurse correctly documents which Glasgow Coma Scale (GCS)rating for this patient?

A) 12
B) 13
C) 14
D) 15

Question 18

The nurse is caring for the patient who has had an injury to the hypothalamus.Which intervention is most important for the nurse to implement?

A) Closely control room temperature.
B) Monitor for signs of hemorrhage.
C) Protect the patient's eyes from bright lights.
D) Turn the patient hourly to maintain skin integrity.

Question 19

The nurse differentiates the sympathetic from the parasympathetic nervous systems.Which statement about the sympathetic system is accurate?

A) The sympathetic system provides energy for "fight or flight" in stressful situations.
B) The sympathetic system slows the heart rate after a stressful situation.
C) The sympathetic system supports deep sleep after large expenditures of energy.
D) The sympathetic system relaxes blood vessels to counteract hypertension.

Question 20

The nurse is caring for a patient with a head injury.Over a time span of 30 minutes,the nurse observes the following vital signs changes: temperature from 97° to 98° F; pulse from 86 to 78 beats/min; respirations from 18 to 14 breaths/min; and blood pressure from 140/86 to 150/82.Which action is most important for the nurse to take?

A) Notify the physician immediately.
B) Document the findings.
C) Determine the patient's Glasgow Coma Scale (GCS) score.
D) Observe pupils for size, equality, and reactivity.

Question 21

The nurse performs a reflex test on a newly admitted adult patient.The nurse runs a tongue blade along the sole of the foot and the patient responds with the great toe bending backward (upward)and the smaller toes fanning outward.These findings cause the nurse to suspect that the patient may have experienced which problem(s)?

A) Injury to the central nervous system (CNS) that resulted in an abnormality in the motor control pathways leading from the cerebral cortex
B) Myocardial infarction that resulted in hypoxemia
C) Influence of chemical substances
D) Damage to the peripheral nervous system (PNS)
E) Trauma to the hypothalamus

Question 22

During a physical assessment of the neurologic system,the nurse checks the patient's __________,which is built into the nervous system and does not need the intervention of conscious thought to take place.

Question 23

The degree of consciousness in an otherwise unresponsive patient can be assessed by the use of progressive painful stimuli.Arrange the painful stimuli in the appropriate sequence of their application.

Step 2

A)Press on the orbital notch.
B)Press the mandibular angle.
C)Shake gently.
D)Rub sternum.
E)Pinch trapezius.

Question 24

The degree of consciousness in an otherwise unresponsive patient can be assessed by the use of progressive painful stimuli.Arrange the painful stimuli in the appropriate sequence of their application.

Step 5

A)Press on the orbital notch.
B)Press the mandibular angle.
C)Shake gently.
D)Rub sternum.
E)Pinch trapezius.

Question 25

When documenting pupillary response that is normal,the acceptable abbreviation is _______.

Question 26

The degree of consciousness in an otherwise unresponsive patient can be assessed by the use of progressive painful stimuli.Arrange the painful stimuli in the appropriate sequence of their application.

Step 3

A)Press on the orbital notch.
B)Press the mandibular angle.
C)Shake gently.
D)Rub sternum.
E)Pinch trapezius.

Question 27

The degree of consciousness in an otherwise unresponsive patient can be assessed by the use of progressive painful stimuli.Arrange the painful stimuli in the appropriate sequence of their application.

Step 1

A)Press on the orbital notch.
B)Press the mandibular angle.
C)Shake gently.
D)Rub sternum.
E)Pinch trapezius.

Question 28

The component of the peripheral nervous system (PNS)that carries the impulse to the central nervous system (CNS)is the ____________ impulse.

Question 29

A neurologically damaged patient who cannot interpret communication directed to him is said to have ____________ aphasia.

Question 30

There are _______ cranial nerves that control the sensory and motor activities of the body.

Question 31

The degree of consciousness in an otherwise unresponsive patient can be assessed by the use of progressive painful stimuli.Arrange the painful stimuli in the appropriate sequence of their application.

Step 4

A)Press on the orbital notch.
B)Press the mandibular angle.
C)Shake gently.
D)Rub sternum.
E)Pinch trapezius.

Question 32

The FOUR (Full Outline of UnResponsiveness)tool is based on the assessment of which components?

A) Eye response
B) Motor response
C) Brainstem response
D) Respiratory function
E) Reflex response