Deck 24: Neurologic System

Question 1

The nurse is performing a neurological assessment and needs to test cranial nerves.The nurse asks the client to close both eyes and report when a touch with a wisp of cotton is felt.The nurse is assessing the function of which of the following cranial nerves?
1)Trigeminal nerve (cranial nerve V)
2)Abducens nerve (cranial nerve VI)
3)Facial nerve (cranial nerve VII)
4)Optic nerve (cranial nerve II)

Answer 1

1

Question 2

The nurse is caring for a client with a traumatic brain injury.The client has begun to experience bradycardia.What area of the brain is likely responsible for the changes in heart rate?

Answer 2

Question 3

The nurse is interviewing a client with suspected Lyme disease.Which of the following questions would be a priority in this situation?
1)"When was your last seizure?"
2)"Have you been hiking or camping lately?"
3)"What has your temperature been running?"
4)"Do you have an appetite?"

Answer 3

2

Question 4

The nurse is performing a neurological assessment on a client experiencing anosmia.The nurse would suspect cranial nerve involvement in which of the following?
1)Trochlear (cranial nerve IV)
2)Trigeminal (cranial nerve V)
3)Olfactory (cranial nerve I)
4)Oculomotor (cranial nerve III)

Question 5

The nurse is interviewing a client and notes that the left eyelid is drooping.The nurse would correctly chart which of the following conditions?
1)Ptosis
2)Nystagmus
3)Strabismus
4)Myopia

Question 6

Review the 2 photographs below.Which of the following cranial nerves is being evaluated by this activity being demonstrated?
1)Trigeminal nerve (cranial nerve V)
2)Facial nerve (cranial nerve VII)
3)Vagus nerve (cranial nerve X)
4)Hypoglossal nerve (cranial nerve XII)

Question 7

The nurse is admitting a client with suspected meningitis and notes a positive Brudzinski's sign has been noted in the history and physical.To validate this assessment finding,the nurse would note which of the following?
1)Seizure activity
2)Neck pain and stiffness
3)Flexion of the legs and thighs
4)Neck extension

Question 8

The nurse is assessing cranial nerve XI (spinal accessory).Which of the following statements would the nurse say to the client?
1)"Shrug your shoulders and turn your head against my hand."
2)"Stick out your tongue and move it from side to side."
3)"Taste these foods and decide which is sweet and which is sour."
4)"Smell these items and identify what they are."

Question 9

The nurse is performing the Romberg test and asks the client to stand with the feet together and eyes closed.The nurse notes the findings are normal.Which of the following client responses occurred in this situation? The client:
1)Swayed from side to side.
2)Had minimal swaying.
3)Felt moderately dizzy.
4)Had complete loss of balance.

Question 10

The nurse performing reflex testing on a client uses the reflex hammer to gently strike the forearm about two inches above the wrist.The nurse is assessing which of the following reflexes?
1)Brachioradialis
2)Biceps
3)Triceps
4)Achilles

Question 11

The nurse is examining a client experiencing vertigo and wants to perform the Romberg test.The nurse would correctly provide which set of instructions to the client?
1)"Touch your finger to your nose,alternating hands."
2)"Walk across the room by placing one foot in front of the other,heel to toes."
3)"Walk on your toes,then on your heels,then on your toes again."
4)"Stand with your feet together,arms at sides,and eyes open."

Question 12

The nurse is assessing the patellar reflex on a client and obtains no reflexive activity.The client is alert and oriented.The nurse should do which of the following in this situation?
1)Document the findings as normal.
2)Notify the healthcare provider immediately.
3)Look at the medication records for central nervous system depressants.
4)Retest the reflex after having the client use distraction during the exam.

Question 13

The student nurse is reviewing the cranial nerves.The student recognizes some of the nerves are exclusively sensory nerves.Which of the following cranial nerves belong to this group?
1)Olfactory nerve (cranial nerve I)
2)Optic nerve (cranial nerve II)
3)Trochlear nerve (cranial nerve IV)
4)Trigeminal nerve (cranial nerve V)
5)Facial nerve (cranial nerve VII)

Question 14

The nurse in the photograph is performing an assessment on which of the following cranial nerves?
1)Olfactory nerve (cranial nerve I)
2)Optic nerve (cranial nerve II)
3)Oculomotor nerve (cranial nerve III)
4)Trochlear nerve (cranial nerve IV)

Question 15

The nurse is performing a neurological assessment on a client and needs to use stereognosis[0] Which of the following instructions would the nurse provide for the client?
1)"Tell me if you feel one or two objects touching you with your eyes closed."
2)"Identify the object in your hand with your eyes closed."
3)"Identify the number being traced in your hand with your eyes closed."
4)"Open and close your hand each time I tell you to."

Question 16

The nurse observes drainage from a client's ears after a head injury,and suspects a cerebral spinal fluid (CSF)leak.Which of the following descriptions would best support this finding?
1)Yellow without sediment
2)Blood-tinged without sediment
3)Clear,colorless
4)Pink without sediment

Question 17

The nurse has assessed a client and notes diminished reflexes.The nurse would correctly document which of the following?
1)4+/0-4+
2)3+/0-4+
3)2+/0-4+
4)1+/0-4+

Question 18

The nurse is assessing a client to determine tremors associated with Parkinson's disease.The nurse would correctly observe for which of the following movements?
1)Fasciculations
2)Chorea
3)Rhythmic shaking
4)Athetoid movements

Question 19

The nurse is caring for a client having problems with emotional appropriateness as a result of a brain injury.Mark the area that has most likely been damaged.

Question 20

The nurse is performing a neurological assessment and needs to assess for vibration,as well as sharp and dull sensation.The nurse would use which of the following objects to obtain this information?
1)Tuning fork
2)Paper clip
3)Safety pin
4)Cotton ball
5)Tongue blade

Question 21

The nurse is preparing a neurological health seminar for the staff on the unit.Which of the following statements would the nurse include in the teaching plan?
1)Older adults experience fewer accidents and injuries.
2)Alcohol or drug use increases the risk for accidents and injury.
3)Head injuries are more common in adults than children.
4)Epilepsy occurs only in children under age 15.

Question 22

The community health nurse is preparing a program geared toward primary prevention of hypertension.When preparing the program,what activities will aid the nurse in meeting the goals of primary prevention?
1)Providing dietary counseling for clients with hypertension
2)Offering free blood pressure screening to participants
3)Having a contest for participants to win an automatic blood pressure cuff for home use
4)Providing literature to discuss modifiable risk factors

Question 23

The nurse is reviewing questions to include in a focused assessment on a client who has presented to the clinic with complaints of back pain.Which of the following questions should be included in the interview?
1)"How long have you been experiencing this pain?"
2)"What activities seem to increase your pain?"
3)"Do any members of your family have neurological problems?"
4)"What things do you do to relieve your pain?"
5)"Are you able to perform your employment responsibilities since the pain began?"

Question 24

The nurse is assessing cognitive function in a client who experienced a cerebral vascular accident.The nurse should focus on which of the following?
1)Ability to smell items while eyes are closed
2)Orientation to time,place,and person
3)Ability to walk with a smooth,steady gait
4)Ability to speak clearly

Question 25

The nurse is admitting a client with suspected meningitis.During the assessment,the nurse asks the client to flex the chin down toward the chest.The client verbalizes pain and stiffness during this action.The nurse would document this as which of the following?
1)Muscle spasms
2)Neck strain
3)Nuchal rigidity
4)Brudzinski's sign

Question 26

The nurse notes that a client has difficulty with ambulation due to an unsteady gait.The nurse would correctly document this finding as which of the following?
1)Flaccidity
2)Paralysis
3)Hemiparesis
4)Ataxia

Question 27

The nurse is interviewing a client that states he does not have any feeling on right side of the body.After confirmation of this subjective data,the nurse would correctly document which of the following?
1)Anesthesia
2)Analgesia
3)Hypalgesia
4)Hypoesthesia

Question 28

The nurse is reviewing the history and physical on a client and notes a history of syncope.The nurse would implement which of the following for this client?
1)Soft diet
2)Seizure precautions
3)Fall precautions
4)Intake and output

Question 29

The nurse is observing a client's ambulation abilities and notes a scissors gait.The nurse would suspect which of the following disorders in this client?
1)Parkinson's disease
2)Multiple sclerosis
3)Myasthenia gravis
4)Muscular dystrophy

Question 30

The nurse is providing education to a group of pregnant women.The nurse should stress which of the following as the greatest tool in the prevention of low-birth-weight babies?
1)Early prenatal care
2)Eating a balanced diet
3)Avoiding stress
4)Regular exercise

Question 31

The nurse is providing discharge instructions to the mother of a child admitted for fever of unknown origin.Which of the following statements,if made by the mother,would indicate the need for further instruction?
1)"I should use Tylenol or aspirin to bring down the temperature."
2)"I should contact the doctor if I cannot wake up my child."
3)"I should observe how much my child urinates."
4)"I should monitor my child's intake of fluids throughout the day."

Question 32

While interviewing a client the nurse notes the client's eyes moving involuntarily.The nurse would correctly document which of the following findings?
1)Nystagmus
2)Presbyopia
3)Anosmia
4)Polyneuritis

Question 33

The nurse notes fanning of the toes when the sole of the foot is stimulated during assessment of the plantar reflex.The nurse would correctly chart which of the following?
1)Hyperreflexia
2)Babinski response
3)Brudzinski sign
4)Nuchal rigidity