Deck 41: Assessing the Nervous System

Question 1

The nurse is assessing a patient's muscle strength and movement. What should the nurse do when completing this assessment?

A) grade the posterior tibial pulses
B) grade flaccidity
C) observe whether strength and movement are bilaterally equal and strong
D) ask the patient to walk normally in a heel-to-toe sequence

Answer 1

observe whether strength and movement are bilaterally equal and strong

Question 2

While assisting with a lumbar puncture, the nurse determines that a patient's cerebrospinal (CSF) fluid is normal. What did the nurse assess to make this clinical decision?

A) The CSF is yellow, without sediment.
B) The CSF is tinged with blood but has no sediment.
C) The CSF is clear and colorless.
D) The CSF is pink, without sediment.

Answer 2

The CSF is clear and colorless.

Question 3

A patient is being treated for a common neurological disease that is characterized by abnormal cell firing in the brain. For what should the nurse assess in this patient?

A) loss of consciousness
B) seizures
C) decerebrate posturing
D) headache

Answer 3

seizures

Question 4

The nurse asks the patient to walk heel-to-toe, on the toes, and then on the heels. What function is the nurse assessing?

A) cerebellar
B) cerebral
C) midbrain
D) brainstem

Question 5

A patient is in the hospital with suspected intracerebral hemorrhage. The nurse anticipates that which neurological test is likely to be ordered?

A) x-rays of the spine
B) computed tomography (CT)
C) evoked potentials
D) electroencephalogram (EEG)

Question 6

The patient has lower motor neuron injuries. What type of reflexes should the nurse expect to assess in this patient?

A) decreased
B) increased
C) normal
D) exaggerated

Question 7

The nurse understands that age-related changes in the neurological system include a decreased number of brain cells, decreased cerebral blood flow, and decreased metabolism. How would these expectations affect the nurse's plan when caring for an older patient at home?

A) The older adult will be distracted after a few minutes on the task.
B) The older adult will not be open to learning to perform his or her own dressing change.
C) The older adult will be less reliable at completing self-care activities.
D) When too many stimuli are present, the older adult cannot process and respond in a timely fashion.
E) The older adult has an increased risk for falls.

Question 8

The nurse is preparing to assess a patient's cognitive function. What should the nurse include in this assessment?

A) ability to smell items placed under the nose while eyes are closed
B) orientation to time, place, and person, and ability to recall recent and past events
C) ability to walk with a smooth, steady gait
D) level of consciousness

Question 9

A patient in the hospital critical care unit is being evaluated for brain death. What neurological test should the nurse expect to be prescribed for this patient?

A) electroencephalogram (EEG)
B) computed tomography (CT)
C) evoked potentials
D) electromyogram (EMG)

Question 10

A patient is seen in the clinic for a neuromuscular disease. What neurological test helps to diagnose this type of health problem?

A) single-photon emission computed tomography (SPECT)
B) positron emission tomography (PET)
C) magnetic resonance imaging (MRI)
D) electromyogram (EMG)

Question 11

The nurse is preparing to assess a patient's cranial nerve XI (spinal accessory). What should the nurse ask the patient to complete this assessment?

A) Shrug the shoulders and turn the head against resistance.
B) Stick out the tongue and move it from side to side.
C) Taste foods and distinguish sweet from sour.
D) Smell items with one nostril blocked and identify them correctly.

Question 12

The nurse wants to determine if a patient is experiencing tremors. When performing this assessment, for what should the nurse observe?

A) shaking
B) jerky movements
C) rhythmic movements
D) fasciculations

Question 13

A patient in the supine position with the head flexed to the chest is not experiencing any pain, resistance, or flexion of the hips or knees. What is the nurse assessing in this patient?

A) doll's-eyes reflex
B) Brudzinski sign
C) Babinski reflex
D) Kernig sign

Question 14

The nurse is conducting a seminar on Alzheimer disease (AD) with a group of community members. How should the nurse describe this health problem?

A) The incidence of AD increases with age.
B) AD tends to run in families.
C) AD is more common in men.
D) AD is caused by a virus.
E) AD is caused by environmental contaminants.

Question 15

A victim who was thrown 50 feet in a motor vehicle crash experiences transient consciousness en route to the emergency department. What neurological tests should the nurse expect to be prescribed for this patient?

A) magnetic resonance imaging (MRI) and computed tomography (CT)
B) computed tomography (CT) and positron emission tomography (PET)
C) x-rays of the skull and spine and computed tomography (CT)
D) computed tomography (CT)

Question 16

Normally a patient can differentiate between soft and sharp and can feel vibrations accurately. What should the nurse do to assess a patient's sensory function?

A) touch both sides of various parts of the body with a sharp and a dull object
B) have the patient distinguish which parts of the body are being touched
C) ask the patient to identify two areas of simultaneous pinpricks on the hand
D) write a number on the patient's hand and have him or her identify the number

Question 17

To conduct the Romberg test, the nurse asks the patient to stand with the feet together and eyes closed. What must the nurse observe for the test to be considered normal?

A) swaying from side to side
B) minimal swaying for up to 20 seconds
C) sufficient balance to hold completely still without swaying
D) swaying to one side and loss of balance

Question 18

A patient's family asks the nurse, "What does damage to Broca's area mean?" after the healthcare provider leaves the patient's room. Which is the best response by the nurse?

A) "The way you communicate will have to change."
B) "You'll have to speak very loudly when you talk."
C) "Make sure there are no obstacles in the room, because sight will be a problem."
D) "Perhaps you would like to learn how to provide range-of-motion exercises."

Question 19

The nurse is planning to assess an adult patient with a neurological problem for abnormal posturing. For what postures should the nurse specifically assess?

A) decorticate
B) decerebrate
C) circumduction
D) festinating
E) nystagmus

Question 20

A patient is exhibiting a lack of coordination, clumsy movements, and an unbalanced gait. What term should the nurse use when documenting these observations?

A) flaccidity
B) paralysis
C) hemiparesis
D) ataxia

Question 21

The nurse is planning to assess a patient's brachioradialis reflex. Place an "X" on the picture that represents the technique the nurse will use to test this reflex.

Question 22

The nurse reads that a patient's reflexes are 3+. How should the nurse interpret this finding?

A) The patient's reflexes are weaker than normal.
B) The patient's reflexes are normal.
C) The patient's reflexes are stronger than normal.
D) The patient's reflexes are hyperactive.

Question 23

The nurse is assessing the patient using the technique shown. Which finding should the nurse consider normal?

A) pain only at the hip during flexion
B) resistance in the hip joint
C) a clicking sound in the knee upon flexion
D) no pain or resistance in either hip or knee joint

Question 24

A patient reports hearing noises when alone in a quiet room. What action should the nurse take?

A) make sure the patient is referred to a psychiatrist
B) document that the patient has a mental illness
C) ask if the patient experiences any visual disturbances
D) explain to the patient that this is not unusual

Question 25

During an assessment of a patient's cranial nerves, the nurse states, "Please stick out your tongue." The nurse observes that the tongue deviates markedly to the right side. What is the patient most likely exhibiting?

A) abnormal hypoglossal nerve response
B) first cranial nerve (CN I) damage
C) sluggish oculomotor response
D) absence of the Homans sign

Question 26

The meal tray for a patient with damage to the glossopharyngeal nerve (CN IX) has been delivered. What action should the nurse take first?

A) tell the patient what food is on the tray
B) assess the patient's ability to swallow
C) speak loudly and make eye contact with the patient
D) assist the patient in identifying where items are on the tray

Question 27

The nurse is preparing to conduct an assessment of a patient's neurological status. What is the nurse assessing for in this diagram?

A) Kernig sign
B) Babinski reflex
C) Brudzinski sign
D) decorticate posturing

Question 28

The nurse asks a patient who has suffered a cerebral vascular accident (CVA) to complete the heel-to-shin test. What is the nurse testing for with this technique?

A) ataxia
B) graphesthesia
C) coordination
D) spasticity

Question 29

The patient sustained a head injury in a fall and now is having problems seeing. Place an X on the area of the brain where the nurse suspects this patient has been injured.

Question 30

The nurse is caring for a patient with lesions in the corticospinal tracts. Place an "X" on the position that the nurse should expect to assess in this patient?

Question 31

The nurse is reviewing the part of the nervous system that controls cardiac rate, blood pressure, respiration, and swallowing with the family of a patient with a stroke. Which structure should the nurse identify as controlling these functions?

Question 32

The nurse observes signs that a patient may be experiencing dysfunction related to the acoustic nerve (CN VIII). Which actions should the nurse take to minimize the patient's risk for injury?

A) identifying the patient's fall risk category
B) assessing the patient's gag reflex prior to offering food or liquids
C) assisting the patient with bedside sitting or toileting
D) assessing the patient's vision using a Snellen chart
E) placing a red "falls risk" bracelet on the patient's arm

Question 33

An emergency department (ED) nurse receives a report that an incoming patient has a Glasgow Coma Scale (GCS) score of 8. Which is the most appropriate action by the nurse?

A) to treat the patient's pain
B) to assess the patient's airway, breathing, and circulation
C) to obtain a complete history from the patient
D) to triage the patient with the other ED patients

Question 34

The nurse is conducting a health history with a patient exhibiting signs of Parkinson disease. Which question should the nurse ask the patient?

A) "Do you recall if any of your relatives had difficulty holding on to things with their hands?"
B) "Do you remember what you ate for breakfast this morning?"
C) "Is it painful to flex your chin to your chest?"
D) "Did your muscle weakness first occur in your arms or in your legs?"

Question 35

The nurse is conducting a neurological assessment of a patient. Place an "X" on the technique the nurse should use to test for graphesthesia.

Question 36

During a health assessment interview, the nurse notices the patient has a fine tremor in the right hand and arm. The patient says, "They tell me this is a primary essential tremor. What does that mean?" What is the best response by the nurse?

A) "Essential tremor occurs 5 to 10 years before the onset of Parkinson disease."
B) "When essential tremor is a primary disorder, it is usually inherited."
C) "Essential tremor is very rare. It affects only about 100,000 people."
D) "People with essential tremor often go on to develop cardiovascular disease."

Question 37

During a health history the nurse plans to assess the functioning of a patient's central nervous system (CNS). Which question should the nurse ask to assess this function?

A) "Do you get dizzy when moving from a sitting to standing position?"
B) "Do you have difficulty adjusting to changes in temperature?"
C) "Do you have difficulty falling asleep in the evening?"
D) "Have you had any weight loss?"

Question 38

A patient experiencing extreme emotional stress is observed to be exhibiting both tachycardia and tachypnea. Which component of the patient's nervous system is responsible for normalizing the patient's response?

A) central
B) peripheral
C) sympathetic
D) parasympathetic

Question 39

A patient is prescribed a medication that affects the beta₁- and beta₂-receptors in the body. Which effects of this medication should the nurse expect to assess?

A) normal heart rate
B) improved respiration
C) lower blood pressure
D) reduced muscle cramps
E) increased blood glucose level

Question 40

A patient is brought to the emergency department following a motor vehicle accident. The patient jerks away from the nurse attempting to start an IV in the right arm and says, "Bring me my book. I need to eat." When asked what happened in the accident, the patient looks frantically from nurse to nurse and says, "I have a dog." Calculate the patient's Glasgow Coma score. Record your answer rounding to the nearest whole number.

Question 41

A patient is being evaluated for disease of the lower motor neurons. Which assessment findings should the nurse identify as consistent with this health problem?

A) spasticity
B) flaccidity
C) steppage gait
D) fasciculations
E) muscle atrophy

Question 42

The nurse is concerned that a patient is experiencing sympathetic nervous system effects after a head injury. What did the nurse assess to make this clinical decision?

A) damp skin
B) cold extremities
C) heart rate 68 bpm
D) deep, rapid respirations
E) elevated blood pressure

Question 43

During a health history the nurse becomes concerned that a patient is at risk for a neurological problem because of occupational and social hazards. What findings caused the nurse to have this concern?

A) The patient smokes 1 ppd of cigarettes.
B) The patient and spouse walk the family dog after dinner.
C) The patient works in a chemical plant that manufactures plastic.
D) The patient plays football with college friends every Saturday afternoon.
E) The patient rides a motorcycle in a state where headgear is not mandatory.