Deck 22: Neurologic Clinical Assessment and Diagnostic Procedures

Question 1

The nurse is caring for a patient with a head injury who is obtunded.The nurse is going to use noxious stimuli to elicit a response.What is an acceptable method?

A) Nipple pinch
B) Nail bed pressure
C) Supraorbital pressure
D) Sternal rub

Answer 1

Nail bed pressure

Question 2

The nurse knows that change in pupil size is a significant neurologic finding particularly in the patient with a head injury.How much of a size difference between the two pupils is still considered normal?

A) 1 mm
B) 1.5 mm
C) 2 mm
D) 2.5 mm

Answer 2

1 mm

Question 3

A patient is admitted with an anoxic brain injury.The nurse notes abnormal extension of both extremities to noxious stimuli.This finding indicates dysfunction in which area of the central nervous system?

A) Cerebral cortex
B) Thalamus
C) Cerebellum
D) Brainstem

Answer 3

Brainstem

Question 4

Which of the following statements best describes assessment of arousal?

A) It measures content of consciousness and is a higher-level function.
B) It is an evaluation of the reticular activating system and its connection with the thalamus and the cerebral cortex.
C) It becomes a valid parameter when the patient is able to respond to verbal stimuli, such as squeezing the hands on command.
D) Noxious stimuli are not to be used as an assessment parameter.

Question 5

The nurse is precepting a nursing student.The student asks about testing of extraocular eye movements.What should the nurse tell the student?

A) It tests the pupillary response to light.
B) It tests function of the three cranial nerves.
C) It tests the ability of the eyes to accommodate to a closer moving object.
D) It tests the oculocephalic reflex.

Question 6

The nurse is precepting a new graduate nurse.The new graduate asks about testing the oculovestibular reflex.What should the nurse tell the new graduate?

A) The test should not be performed on an unconscious patient because of the risk of aspiration.
B) An abnormal response is manifested by conjugate, slow, tonic nystagmus, deviating toward the irrigated ear.
C) This test should be included in the nursing neurologic examination of a patient with a head injury.
D) This test is one of the final clinical assessments of brainstem function.

Question 7

The nurse is caring for a severely head injured comatose patient who is dying.The nurse knows the patient has entered the late stages of intracranial hypertension when the nurse observes which signs?

A) Pupils are equal and reactive
B) Widening pulse pressure
C) Eupnea
D) Decreased intracranial pressure

Question 8

While the Glasgow Coma Scale (GCS)is part of the routine neurologic assessment,the nurse knows that it is not a valid measure for certain types of patients.In which patient is the GCS not valid?

A) Patient with hemiplegia
B) Patient with Parkinson disease
C) Patient with dyslexia
D) Patient who is intoxicated

Question 9

The nurse is caring for a patient who has sustained a traumatic head injury.The practitioner has asked the nurse to test the patient's oculocephalic reflex.Which findings indicate that the patient has an intact oculocephalic reflex?

A) The patient's eyes move in the same direction the head is turned.
B) The patient's eyes move in the opposite direction to the movement of the patient's head.
C) The patient's eyes rove and move in opposite directions from each other.
D) The patient's eyes move up and down and then back and forth.

Question 10

The nurse is caring for a patient with a closed head injury with a Glasgow Coma Scale (GCS)score of 6.What does this score indicate about the patient's neurologic status?

A) Patient is in a vegetative state.
B) Patient is a paraplegic.
C) Patient is in a coma.
D) Patient is able to obey commands.

Question 11

A patient is admitted to the critical care unit with a subdural hematoma.The nurse is assessing the patient's Glasgow Coma Scale (GCS)score.Which statement is true concerning the GCS?

A) It provides data about level of consciousness only.
B) It is considered equivalent to a complete neurologic examination.
C) It is a sensitive tool for evaluation of an altered sensorium.
D) It is the most critical assessment parameter to account for possible aphasia.

Question 12

The nurse is caring for a patient who has sustained a traumatic head injury.The practitioner has asked the nurse to test the patient's oculocephalic reflex.What must the nurse verity prior to performing the test?

A) The absence of cervical injury
B) The depth and rate of respiration
C) The patient's ability to swallow
D) The patient's ability to follow a verbal command

Question 13

The nurse is caring for a patient with a head injury and observes a rhythmic increase and decrease in the rate and depth of respiration followed by brief periods of apnea.What should the nurse document under breathing pattern?

A) Central neurogenic hyperventilation
B) Apneustic breathing
C) Ataxic respirations
D) Cheyne-Stokes respirations

Question 14

The nurse is caring for a patient immediately after a craniotomy.When assessing the size and shape of the patient's pupils the nurse notes the patient's left pupil is oval.What does this finding indicate?

A) Cortical dysfunction
B) Intracranial hypertension
C) Hydrocephalus
D) Metabolic coma

Question 15

The nurses are admitting a neurologically impaired patient.The patient's family is present.How comprehensive should the initial history be?

A) It should be limited to the chief complaint and personal habits.
B) It should be all-inclusive, including events preceding hospitalization.
C) It should be confined to current medications and family history.
D) It should be restricted to only information that the patient can provide.

Question 16

The nurse is caring for a severely head injured comatose patient who is dying.The practitioner asks to be notified when the patient starts to exhibit signs of Cushing reflex.The nurse would call the practitioner when the patient starts to show what signs?

A) Bradycardia, systolic hypertension, and widening pulse pressure
B) Tachycardia, systolic hypotension, and tachypnea
C) Headache, nuchal rigidity, and hyperthermia
D) Bradycardia, aphasia, and visual field disturbances

Question 17

Why is assessment of level of conscious (LOC)the most important aspect of the neurologic examination?

A) The LOC is the most prognostic indicator of the patient's outcome.
B) The LOC is generally limited to the Glasgow Coma Scale making it the quickest part of the assessment.
C) In most situations the LOC deteriorates before any other neurologic changes are noted.
D) The LOC is the easiest part of the neurologic exam and thus is generally performed first.

Question 18

A patient with a serious head injury has been admitted.The nurse knows that certain neurologic findings can indicate the prognosis for the patient.Which finding denotes the most serious prognosis?

A) Decorticate posturing
B) Decerebrate posturing
C) Absence of Babinski reflex
D) Glasgow Coma Scale (GCS) score of 14

Question 19

The nurse is caring for a critically injured patient who can only be aroused by vigorous external stimuli.Which category should the nurse use to document the patient's level of consciousness?

A) Lethargic
B) Obtunded
C) Stuporous
D) Comatose

Question 20

The nurse is starting a peripheral intravenous catheter in the right hand of an unconscious patient.During the procedure the patient reaches over with his left hand and tries to remove the noxious stimuli.How would the nurse document this response?

A) Decorticate posturing
B) Decerebrate posturing
C) Withdrawal
D) Localization

Question 21

Considering anatomic location,which cranial nerve will be affected first by downward pressure onto the infratentorial structures?

A) III
B) VI
C) IX
D) X

Question 22

The nursing is caring for a comatose patient with a brain tumor.When the nurse touches the palm of the patient's hand,the patient grasps the nurse's hand.What is this sign indicative of?

A) There is damage to the brainstem.
B) It's a normal finding.
C) The patient is getting better.
D) Cortical damage is present.

Question 23

The nurse is precepting a new graduate nurse.The new graduate asks about the difference between electroencephalography and evoked potentials.What should the nurse tell the new graduate?

A) Evoked potentials measure and record electric and muscle activity in response to noxious stimuli.
B) Electroencephalography measures cerebral blood flow and oxygen extraction.
C) Evoked potentials measure cerebral electrical impulses generated in response to sensory stimuli.
D) Electroencephalography measures the biochemical changes in the brain to assess metabolic activity.

Question 24

A patient is admitted to the critical care unit with a subdural hematoma.The nurse is assessing the patient's Glasgow Coma Scale (GCS)score.When assessing the patient's best motor response,which movement would receive the lowest score?

A) Abnormal extension
B) Localizing pain
C) Withdrawing from pain
D) Decorticate posturing

Question 25

The nursing management plan for a patient undergoing a water-based contrast myelogram should include intervention?

A) Maintain the patient flat in bed for 4 to 6 hours
B) Observe the puncture sight every 15 minutes for 2 hours for signs of bleeding
C) Keep the patient's head elevated 30 to 45 degrees for 8 hours
D) Administer a sedative to keep the patient from moving around

Question 26

A patient has been admitted with acute confusion and other focal neurologic signs.The practitioner orders magnetic resonance imaging (MRI).The nurse knows in certain situations an MRI is superior to computed tomography (CT).What is one those situations?

A) Brain death determination
B) Detection of central nervous system infection
C) Estimation of intracranial pressure
D) Identification of subarachnoid hemorrhage

Question 27

A patient is undergoing a preoperative evaluation for carotid arteries.What two test should the nurse expect to see ordered for the patient?

A) Ultrasound and magnetic resonance angiography
B) Conventional angiography and evoked potential
C) Computed tomography (CT) and magnetic resonance angiography
D) Transcranial Doppler and extracranial Doppler

Question 28

A patient has been admitted with acute confusion and other focal neurologic signs.The practitioner is going to perform a lumbar puncture.What is an abnormal finding in the cerebrospinal fluid?

A) Clear and colorless
B) Glucose of 60 mg/dL
C) Protein of 20 mg/dL
D) 30 red blood cells

Question 29

Which patient may need sedation before having a magnetic resonance imaging (MRI)scan?

A) Claustrophobic patient
B) Comatose patient
C) Elderly patient
D) Patient with a spinal cord injury

Question 30

A patient is going for digital subtraction angiography.The patient education plan to prepare the patient for the procedure should include which instruction?

A) Inform the patient that the procedure is very noisy and earplugs will be provided
B) Tell the patient that repositioning will be required at appropriate intervals
C) Instruct the patient to remaining motionless during the entire procedure
D) Let the patient know he will be expected to swallow frequently during the procedure

Question 31

The patient is ordered a computed tomography (CT)scan with contrast.Which question should the nurse ask the conscious patient before the procedure?

A) "Are you allergic to penicillin?"
B) "Are you allergic to iodine-based dye?"
C) "Are you allergic to latex?"
D) "Are you allergic to eggs?"

Question 32

The nurse is caring for a patient with an intracranial pressure-monitoring device that provides access to cerebrospinal fluid (CSF)for sampling.What type of device does the patient have?

A) Subarachnoid bolt
B) Epidural catheter
C) Intraventricular catheter
D) Fiber-optic catheter

Question 33

The nurse is caring for a patient who is going to have digital subtraction angiography.The patient asks what is the difference between conventional and digital subtraction angiography.What should the nurse tell the patient?

A) Digital subtraction angiography has fewer complications.
B) Digital subtraction angiography is noninvasive.
C) Digital subtraction angiography uses significantly less dye.
D) Digital subtraction angiography is done through the femoral vein.

Question 34

Which nuclear medicine study should the nurse anticipate a practitioner's order for in a patient who is being evaluated for a brain tumor?

A) PET
B) MRI
C) MRA
D) SPECT

Question 35

A patient has been admitted with acute confusion and other focal neurologic signs.The practitioner is going to perform a lumbar puncture.What is the most serious complication of lumbar puncture?

A) Meningitis
B) Dural tear
C) Brainstem herniation
D) Spinal cord trauma

Question 36

The practitioner has ordered a carotid Doppler study for a patient.The patient asks the nurse what the test is for.How should the nurse respond?

A) The test evaluates blood flow in the anterior, middle, or posterior cerebral arteries.
B) The test estimates blood flow velocity thought the carotid arteries.
C) The test assesses arteriovenous circulation in the intracranial space.
D) The test gauges global cerebral blood flow.

Question 37

Cerebral infarction is a serious complication of which procedure?

A) Extracranial Doppler
B) Evoked potential testing
C) Myelography
D) Cerebral angiography

Question 38

The practitioner wishes to evaluate the functional integrity of cerebral motor pathways in a brain-injured patient.Which test should the nurse anticipate the practitioner will order?

A) Electroencephalography
B) Xenon computed tomography (CT)
C) Motor-evoked potentials
D) Emission tomography

Question 39

The nurse is caring for a patient who has just had a cerebral angiogram.Which intervention should be part of the nursing management plan?

A) Ensuring that the patient is adequately hydrated
B) Maintaining the patient on an NPO status
C) Administering antibiotics to the patient
D) Keeping the patient flat in bed for 24 hours

Question 40

Which procedure is the diagnostic study of choice for acute head injury?

A) Magnetic resonance imaging
B) Computed tomography
C) Transcranial Doppler
D) Electroencephalography

Question 41

What sites can be used for monitoring intracranial pressure (ICP)?

A) Intraventricular space
B) Epidural space
C) Jugular veins
D) Subdural space
E) Parenchyma

Question 42

The patient was admitted with a head injury and an intracranial pressure (ICP)monitoring device was placed.The nurse knows to notify the practitioner if what type of wave start to appear on the monitor?

A) A waves
B) B wave
C) C waves
D) D waves

Question 43

Which statements are correct regarding the assessment of motor function in the neurologically impaired patient?

A) The presence of a Babinski reflex is an abnormal finding in an adult.
B) Lower extremity muscle tone is assessed by asking the patient to push or pull his or her foot against resistance.
C) When using noxious stimuli to elicit a motor response, each limb is tested separately.
D) The presence of abnormal extension indicates a less positive outcome for the patient than abnormal flexion.
E) The evaluation of deep tendon reflexes is an essential part of the nursing neurologic assessment.

Question 44

Indications for the use of electroencephalography (EEG)include

A) cerebral infarct.
B) metabolic encephalopathy.
C) confirmation of brain death.
D) altered consciousness.
E) all head injuries.

Question 45

A patient is being prepared for a neurologic work-up.The practitioner is getting ready to perform a lumbar puncture.What is the best position for the nurse to place the patient in for the procedure?

A) Prone
B) Reverse Trendelenburg
C) High Fowler
D) Lateral recumbent position with knees and head slightly tucked.

Question 46

According to the 2007 Brain Trauma Foundation guidelines,the recommended CPP range is:

A) 10 to 30 mm Hg.
B) 30 to 50 mm Hg.
C) 50 to 70 mm Hg.
D) 70 to 85 mm Hg.

Question 47

The nurse and a new graduate nurse are caring for a comatose patient on continuous electroencephalography (cEEG)monitor.The new graduate says "This monitor is great.How come we don't use it on all the neuro patients?" What are the drawbacks to using this type of monitor?

A) Size of machine
B) Expensive
C) Labor-intensive program
D) Requires expertise for interpretation
E) Artifacts from ICU environment

Question 48

A critical care patient is diagnosed with massive head trauma.The patient is receiving brain tissue oxygen pressure (PbtO₂)monitoring.The nurse recognized that the goal of this treatment is to maintain PbtO₂:

A) greater than 20 mm Hg.
B) less than 15 mm Hg.
C) between 15 and 20 mm Hg.
D) between 10 and 20 mm Hg.

Question 49

The patient's intracranial pressure (ICP)reading has gradually climbed from 15 to 23 mm Hg.The nurse's primary action is to:

A) drain off 7 mm of cerebrospinal fluid (CSF) from the catheter.
B) notify the physician.
C) place the patient in a high Fowler position to decrease the pressure.
D) check level of consciousness.