Deck 56: Nursing Assessment: Nervous System

Question 1

A patient is scheduled for a myelogram to confirm the presence of a herniated intervertebral disk. Which information obtained when admitting the patient is most important for the nurse to communicate to the health care provider before the procedure?

A) The patient has an allergy to shellfish.
B) The patient has back pain when lying flat for long periods.
C) The patient had 4 ounces of apple juice 4 hours earlier.
D) The patient is anxious about the test.

Answer 1

The patient has an allergy to shellfish.

Question 2

When reviewing the results of a patient's cerebrospinal fluid analysis, the nurse will notify the health care provider about

A) pH of 7.35.
B) white blood cell count (WBC) of 4/ml (0.004/L).
C) protein 30 mg/dl (0.30 g/L).
D) glucose 30 mg/dl (1.7 mmol/L).

Answer 2

glucose 30 mg/dl (1.7 mmol/L).

Question 3

A patient with a deep, large laceration of the left forearm, which has damaged nerve fibers as well as other tissue, asks the nurse to explain what the effect of the nerve damage will be. The nurse should respond that

A) nerve cells do not regenerate, and the loss of sensation and movement will be permanent.
B) normal motor and sensory function will return once the peripheral nerve cells regenerate.
C) weak sensation and movement will come back because peripheral nerve cells are capable of partial regeneration.
D) some sensory and motor function may return because peripheral nerve fibers can regenerate if cell bodies have not been damaged.

Answer 3

some sensory and motor function may return because peripheral nerve fibers can regenerate if cell bodies have not been damaged.

Question 4

Propranolol (Inderal), an adrenergic blocking agent that inhibits sympathetic nervous system activity, is prescribed for a patient. The nurse monitors the patient for

A) dry mouth.
B) constipation.
C) slowed pulse.
D) urinary retention.

Question 5

To assess the functioning of the optic nerve (CN II), the nurse should

A) apply a cotton wisp strand to the cornea.
B) have the patient read a magazine.
C) shine a bright light into the patient's pupil.
D) check for equal opening of the eyelids.

Question 6

A patient has a lesion that affects lower motor neurons. During assessment of the patient's lower extremities, the nurse expects to find

A) spasticity.
B) flaccidity.
C) hyperactive reflexes.
D) loss of sensation.

Question 7

When a 71-year-old patient who is being admitted to the hospital for minor surgery tells the nurse, "I haven't slept through the night for several years now," the nurse will plan to

A) ask for an order for a mild nighttime sedative.
B) teach the patient about electroencephalographic (EEG) testing.
C) discuss sleep-pattern changes in older people.
D) assess function of the cranial nerves.

Question 8

When performing a focused assessment on a patient with a lesion of the left posterior temporal lobe, the nurse will assess for

A) reasoning and problem-solving abilities.
B) sensation on the left side of the body.
C) understanding of written and oral language.
D) voluntary movement on the right side.

Question 9

A patient is scheduled for a lumbar puncture. The nurse will plan to

A) administer a sedative medication 30 minutes before the procedure.
B) transfer the patient to radiology just before the procedure.
C) place the patient on NPO status for 4 hours before the procedure.
D) help the patient lie on the side in the fetal position for the procedure.

Question 10

When the nurse administers gabapentin (Neurontin), a drug that increases the level of gamma-aminobutyric acid (GABA) in the synapse, the effect the nurse would expect is

A) widespread increases in nervous system activity.
B) suppression of nervous system activity.
C) increased patient alertness and arousal.
D) excitation of the affected postsynaptic neurons.

Question 11

Neurologic testing of the patient by the nurse indicates impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). Based on these findings, the nurse plans to

A) insert an oral airway.
B) withhold oral fluid or foods.
C) provide highly seasoned foods.
D) apply artificial tears every hour.

Question 12

When interviewing an acutely confused patient with a head injury, which of these questions will provide the most useful information?

A) "Have you ever been hospitalized for a neurologic problem?"
B) "Do you have any pain at the present time?"
C) "What have you had to eat in the last 24 hours?"
D) "Can you describe you usual pattern for coping with injury?"

Question 13

In a patient who has a corticospinal tract lesion, the nurse should assess for

A) extremity movement and strength.
B) cranial nerve function.
C) peripheral sensitivity to pain.
D) level of consciousness (LOC).

Question 14

A patient with a brainstem infarction is admitted to the nursing unit. The priority nursing assessment for the patient is

A) level of consciousness.
B) pupil reaction to light.
C) respiratory rate and rhythm.
D) reflex reaction time.

Question 15

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

A) The new nurse tests for light touch before testing for pain.
B) The new nurse has the patient close the eyes during testing.
C) The new nurse tells the patient, "You may feel a pinprick now."
D) The new nurse uses an irregular pattern to test for intact touch.

Question 16

The following orders are received for a patient who is unconscious after a head injury caused by an automobile accident. Which one should the nurse question?

A) Perform neurologic checks every 15 minutes.
B) Prepare the patient for lumbar puncture.
C) Obtain x-rays of the skull and spine.
D) Do computed tomography (CT) scan with and without contrast.

Question 17

When obtaining a health history from a patient with a neurologic problem, which question by the nurse will elicit the most useful response from the patient?

A) "Do you ever have any nausea or dizziness?"
B) "Does the pain radiate from your back into your legs?"
C) "Do you have any sensations of pins and needles in your feet?"
D) "Can you describe the sensations you are having in your chest?"

Question 18

During the neurologic assessment, the patient cooperates with the nurse's directions to grip with the hands and to move the feet but does not respond to the nurse's questions. The nurse will suspect

A) a temporal lobe lesion.
B) injury to the cerebellum.
C) a brainstem lesion.
D) damage to the frontal lobe.

Question 19

When admitting a patient with acute confusion to the hospital, the nurse will interview the patient about health problems and health history primarily to

A) determine the patient's motivation for self-care.
B) include the patient in health care decisions.
C) use the information given by the patient to guide care.
D) assess the patient's baseline

Question 20

When developing a plan of care for a patient with dysfunction of the cerebellum, the nurse will include interventions to

A) improve short-term memory.
B) stabilize mood.
C) prevent falls.
D) enhance the ability to swallow.

Question 21

The nurse notes in the patient's medical history that the patient has a positive Romberg test. Which nursing diagnosis is appropriate?

A) Risk for falls related to dizziness or weakness
B) Disturbed tactile sensory perception related to spinal cord damage
C) Ineffective thermoregulation related to decreased vasomotor response
D) Acute pain related to hyperreflexia and spasm