Question 1

The nurse is reviewing a patient's medical record and notes that he is in a coma.Using the Glasgow Coma Scale,which number indicates that the patient is in a coma?

Accepted Answer

A)  6 
B)  12 
C)  15 
D)  24

Question 2

A patient with lack of oxygen to his heart will have pain in his chest and possibly the shoulder,arms,or jaw.The nurse knows that the statement that best explains why this occurs is which of these?

Accepted Answer

A)  There is a problem with the sensory cortex and its ability to discriminate the location. 
B)  The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing pain. 
C)  The sensory cortex does not have the ability to localize pain in the heart, so the pain is felt elsewhere. 
D)  There is a lesion in the dorsal root that is preventing the sensation from being transmitted normally.

Question 3

A 59-year-old patient has a herniated intervertebral disk.Which of the following findings should the nurse expect to see on physical assessment of this individual?

Accepted Answer

A)  Hyporeflexia 
B)  Increased muscle tone 
C)  A positive Babinski's sign 
D)  The presence of pathologic reflexes

Question 4

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand.He also cries and becomes angry very easily.The nurse recalls that the cerebral lobe responsible for these behaviors is the _____ lobe.

Accepted Answer

A)  frontal 
B)  parietal 
C)  occipital 
D)  temporal

Question 5

The nurse is testing superficial reflexes on an adult patient.When stroking up the lateral side of the sole and across the ball of the foot,the nurse notices the plantar flexion of the toes.How should the nurse document this finding?

Accepted Answer

A)  Positive Babinski sign 
B)  Plantar reflex abnormal 
C)  Plantar reflex present 
D)  Plantar reflex "2+" on a scale from "0 to 4+"

Question 6

During the history of a 78-year-old man,his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." In doing the assessment of his sensory system,which action by the nurse is most appropriate?

Accepted Answer

A)  The nurse would not do this part of the examination because results would not be valid. 
B)  The nurse would perform the tests, knowing that mental status does not affect sensory ability. 
C)  The nurse would proceed with the explanations of each test, making sure the wife understands. 
D)  Before testing, the nurse would assess the patient's mental status and ability to follow directions at this time.

Question 7

During the neurologic assessment of a "healthy" 35-year-old patient,the nurse asks him to relax his muscles completely.The nurse then moves each extremity through full range of motion.Which of these results would the nurse expect to find?

Accepted Answer

A)  Firm, rigid resistance to movement 
B)  Mild, even resistance to movement 
C)  Hypotonic muscles as a result of total relaxation 
D)  Slight pain with some directions of movement

Question 8

When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed,he starts to sway and moves his feet farther apart.The nurse would document this finding as a(n):

Accepted Answer

A)  ataxia. 
B)  lack of coordination. 
C)  negative Homans' sign. 
D)  positive Romberg sign.

Question 9

While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier,he tells the nurse that he is on a cruise ship and is 30 years old.The nurse knows that this finding is indicative of:

Accepted Answer

A)  a great sense of humor. 
B)  uncooperative behavior. 
C)  inability to understand questions. 
D)  decreased level of consciousness.

Question 10

The nurse places a key in the hand of a patient and he identifies it as a penny.What term would the nurse use to describe this finding?

Accepted Answer

A)  Extinction 
B)  Astereognosis 
C)  Graphesthesia 
D)  Tactile discrimination

Question 11

In the assessment of a 1-month-old infant,the nurse notices a lack of response to noise or stimulation.The mother reports that in the last week he has been sleeping all the time,and when he is awake all he does is cry.The nurse hears that the infant's cries are very high pitched and shrill.What should be the nurse's appropriate response to these findings?

Accepted Answer

A)  Refer the infant for further testing. 
B)  Talk with the mother about eating habits. 
C)  Nothing; these are expected findings for an infant this age. 
D)  Tell the mother to bring the baby back in a week for a recheck.

Question 12

Which of these statements about the peripheral nervous system is correct?

Accepted Answer

A)  The cranial nerves enter the brain through the spinal cord. 
B)  Efferent fibers carry sensory input to the central nervous system through the spinal cord. 
C)  The peripheral nerves are inside the central nervous system and carry impulses through their motor fibers. 
D)  The peripheral nerves carry input to the central nervous system by afferent fibers and away by efferent fibers.

Question 13

When the nurse is testing the triceps reflex,what is the expected response?

Accepted Answer

A)  Flexion of the hand 
B)  Pronation of the hand 
C)  Extension of the forearm 
D)  Flexion of the forearm

Question 14

A patient is not able to perform rapid alternating movements such as patting her knees rapidly.The nurse should document this as:

Accepted Answer

A)  ataxia. 
B)  astereognosis. 
C)  the presence of dysdiadochokinesia. 
D)  loss of kinesthesia.

Question 15

The nurse is doing an assessment on a 29-year-old woman who visits the clinic complaining of "always dropping things and falling down." While testing rapid alternating movements,the nurse notices that the woman is unable to pat both her knees.Her response is very slow and she misses frequently.What should the nurse suspect?

Accepted Answer

A)  Vestibular disease 
B)  Lesion of cranial nerve IX 
C)  Dysfunction of the cerebellum 
D)  Inability to understand directions

Question 16

In a person with an upper motor neuron lesion such as a cerebrovascular accident,which of these physical assessment findings should the nurse expect to see?

Accepted Answer

A)  Hyperreflexia 
B)  Fasciculations 
C)  Loss of muscle tone and flaccidity 
D)  Atrophy and wasting of the muscles

Exam 23: Neurologic System