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Chapter 43: Assessment of the Nervous SystemTest Bank

MULTIPLE CHOICE

1.The nurse assesses a client who has trauma to the cerebrum. Which clinical manifestation does the nurse expect to observe?a.Poor coordinationb.Memory lossc.Hyperthermiad.Slurred speech

ANS:BThe cerebrum is the largest part of the brain and controls intelligence, creativity, and memory. Poor coordination, hyperthermia, and slurred speech are caused by other parts of the brain.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)MSC:Integrated Process: Nursing Process (Assessment)

2.The nurse is assessing a client with a frontal lobe brain injury. Which clinical manifestation does the nurse expect to see?a.Inability to interpret taste sensationsb.Inability to interpret soundc.Impaired judgmentd.Impaired learning

ANS:CThe frontal lobe is responsible for many functions, including judgment, reasoning, voluntary eye movement, and motor functions. The other clinical manifestations are not associated with the frontal lobe.

DIF:Cognitive Level: Knowledge/RememberingREF:Table 43-1, p. 907TOP:Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)MSC:Integrated Process: Nursing Process (Assessment)

3.The nurse is planning to provide discharge teaching related to cardiac medications to a client who has experienced damage to the left temporal lobe of the brain. What does the nurse do to assist the client to understand the content of the instruction?a.Use a larger print size for written materials.b.Ensure that the client is wearing glasses.c.Point out the color of the medication.d.Sit on the clients right side.

ANS:DThe temporal lobe contains the auditory center for sound interpretation. The clients hearing will be impaired in the left ear. The nurse should sit on the clients right side and speak to the right ear. The other interventions do not address the clients left temporal lobe damage.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Psychosocial Integrity (Therapeutic Communication)MSC:Integrated Process: Teaching/Learning

4.After performing a physical assessment on a 75-year-old client, the nurse notes that the client has a hypoactive response to a test of deep tendon reflexes. Which intervention does the nurse include in this clients plan of care?a.Assist the client with ambulation.b.Elevate the clients lower extremities.c.Apply elastic support hose.d.Massage the clients legs.

ANS:AThe older adult experiences certain neurologic changes associated with aging. Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. The nurse or assistive personnel should assist this client with ambulation to prevent injury. The other interventions do not address the clients problem.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Health Promotion and Maintenance (Aging Process)MSC:Integrated Process: Nursing Process (Implementation)

5.The nurse is discharging an 80-year-old client with diminished touch sensation. Which instruction does the nurse provide to promote client safety?a.Walk barefoot only in your home.b.Bathe in warm water to increase your circulation.c.Look at the placement of your feet when walking.d.Put throw rugs at the foot of your bed for cushioning.

ANS:COlder clients with decreased sensation are at risk of injury from the inability to sense changes in terrain when walking. To compensate for this loss, the client is instructed to look at the placement of her or his feet when walking. The client also should wear sturdy shoes for ambulation. Throw rugs can slip and increase fall risk. Bath water that is too warm places the client at risk for thermal injury.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)MSC:Integrated Process: Teaching/Learning

6.A client admitted the previous day for a suspected neurologic disorder becomes increasingly lethargic. Which is the best nursing action?a.Promote a quiet atmosphere for sleep and rest to treat the clients sleep deprivation.b.Explain to the family that this is a normal age-related decline in mental processing.c.Consult a psychiatrist to treat the clients hospital-acquired depression.d.Complete a full neurologic assessment and notify the neurologist.

ANS:DA change in the clients level of consciousness (LOC) is the first indication of a decline in central neurologic functioning. The nurse should conduct a thorough assessment and then should notify the neurologist (or other provider). The other interventions are inappropriate.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)MSC:Integrated Process: Nursing Process (Analysis)

7.The nurse is assessing a clients remote memory. Which statement by the client confirms that remote memory is intact?a.Mary had a little lamb whose fleece was white as snow.b.I was born on April 3, 1967, in Johnstown Community Hospital.c.Apple, chair, and pencil are the words you just stated.d.My sister brought me to the clinic for this appointment.

ANS:BAsking clients about certain facts from the past that can be verified assesses remote, or long-term, memory. The clients ability to make up a rhyme tests not memory, but rather a higher level of cognition. The other statements indicate immediate and recent memory.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Reduction in Risk PotentialSystem-Specific Assessments)MSC:Integrated Process: Nursing Process (Assessment)

8.During a neurologic examination, a client demonstrates a positive Rombergs sign with eyes closed, but not with eyes open. Which condition does the nurse associate with this finding?a.Difficulty with proprioceptionb.Peripheral motor disorderc.Impaired cerebellar functiond.Positive pronator drift

ANS:AThe client who sways with eyes closed (positive Rombergs sign) but not with eyes open most likely has a disorder of proprioception and uses vision to compensate for it. The other options do not explain a positive Rombergs sign.


9.The nurse is assessing the deep tendon reflexes of a client with long-standing diabetes mellitus. Which clinical manifestation does the nurse expect to see?a.Bilateral hypoactive reflexesb.Bilateral hyperactive reflexesc.Asymmetric reflex responsed.Bilateral ankle clonus

ANS:ALong-standing diabetes mellitus causes peripheral neuropathy. Hypoactive responses or no response to stimulation of deep tendon reflexes is one manifestation of diabetes-induced peripheral neuropathy. Other responses are not related to complications of diabetes mellitus.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)MSC:Integrated Process: Nursing Process (Assessment)

10.During a neurologic assessment of a client, the nurse notes that the clients arms, wrists, and fingers have become flexed, and internal rotation and plantar flexion of the legs are evident. How does the nurse document these findings?a.Decorticate posturingb.Decerebrate posturingc.Atypical hyperreflexiad.Spinal cord degeneration

ANS:AThe client is demonstrating decorticate posturing, which is seen with interruption in the corticospinal pathway. This finding is abnormal and is a sign that the clients condition has deteriorated. The physician, the charge nurse, and other health care team members should be notified immediately of this change in status. Decerebrate posturing consists of external rotation and extension of the extremities. The other two options are inaccurate.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)MSC:Integrated Process: Communication and Documentation

11.The nurse is evaluating a clients physical assessment with the medical history and treatment plan. The nurse notes that the clients right pupil appears dilated, with a sluggish pupillary response to light. Which disorder and related treatment does this physical finding correlate with?a.Coronary artery disease and beta blockersb.Diabetes mellitus and oral glycemic reducing agentsc.Glaucoma and intraocular pressurereducing eyedropsd.Myopia and corrective laser surgery

ANS:CClients with glaucoma who are being treated with eyedrops have unequal pupils, especially if only one eye is being treated. The pupillary reaction to light is slowed by the use of eyedrops for glaucoma. The other disorders and treatments do not correlate with the clinical assessment.


12.Before electroencephalography, a client asks, Why will I be asked to take deep breaths during the procedure? How does the nurse respond?a.Hyperventilation causes cerebral vasodilatation and increases the likelihood of seizure activity.b.Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity.c.Deep breathing will keep you relaxed and will lower the seizure threshold.d.Deep breathing will make you hypoxemic, which lowers the seizure threshold.

ANS:BHyperventilation produces cerebral vasoconstriction and alkalosis, which increases the likelihood of seizure activity. The client is asked to breathe deeply 20 to 30 times for 3 minutes. The other responses are not appropriate.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests)MSC:Integrated Process: Teaching/Learning

13.The nurse is caring for a client post-cerebral angiography via the clients right femoral artery. Which intervention does the nurse implement?a.Check the right lower extremity pulses.b.Measure orthostatic blood pressure.c.Perform a funduscopic examination.d.Assess the clients gag reflex.

ANS:ACerebral angiography is performed by threading a catheter through the femoral or brachial artery. The extremity is kept immobilized after the procedure. The nurse checks the extremity for adequate circulation by noting skin color and temperature, presence and quality of pulses distal to the injection site, and capillary refill. Clients usually are on bedrest; therefore orthostatic blood pressure cannot be performed. The funduscopic examination would not be affected by cerebral angiography. The client is given analgesics but not conscious sedation; therefore the clients gag reflex would not be compromised.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests/Treatments/Procedures)MSC:Integrated Process: Nursing Process (Assessment)

14.The nurse is preparing a client for magnetic resonance angiography. Which question is a priority at this time?a.Have you had a recent blood transfusion?b.Do you have allergies to iodine or shellfish?c.Do you have a history of urinary tract infections?d.Do you currently use oral contraceptives?

ANS:BAllergies to iodine and/or shellfish need to be explored because the client may have a similar reaction to the dye used in the procedure. In some cases, the client may need to be medicated with antihistamines or steroids before the test is given. The other conditions would not affect the angiography.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlAccident/Injury Prevention)MSC:Integrated Process: Nursing Process (Assessment)

15.The nurse is caring for a client who had a computed tomography (CT) scan of the head with contrast medium. Which priority intervention does the nurse implement?a.Maintain bedrest with the head of the bed elevated less than 30 degrees.b.Apply a pressure dressing to the site of injection.c.Increase fluid intake after the procedure.d.Maintain sedation for 8 hours postprocedure.

ANS:CIf a contrast medium is used, intravenous fluid may be given to promote excretion of the contrast medium. Contrast medium also may act as a diuretic, resulting in the need for fluid replacement. The client will not be sedated for the procedure and will not require bedrest. Contrast is injected through a peripheral IV.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests/Treatments/Procedures)MSC:Integrated Process: Nursing Process (Implementation)

16.The nurse is obtaining the health history of a client scheduled for magnetic resonance imaging (MRI). Which condition requires the nurse to cancel the MRI?a.Amputated legb.Internal insulin pumpc.Intrauterine deviced.Atrioventricular (AV) graft

ANS:BMetal devices such as pacemakers and prostheses interfere with the accuracy of the image and can become displaced by the magnetic force generated by an MRI procedure. An intrauterine device and an AV graft do not contain any metal.

DIF:Cognitive Level: Comprehension/UnderstandingREF:p. 921TOP:Client Needs Category: Health Promotion and Maintenance (Health Screening)MSC:Integrated Process: Nursing Process (Planning)

17.Which priority instruction or precaution does the nurse teach a client who is scheduled for a positron emission tomography scan of the brain?a.Avoid caffeine-containing substances for 12 hours before the test.b.Drink at least 3 liters of fluid during the 24 hours after the test.c.Do not take your cardiac medication on the morning of the test.d.Remove your dentures and any metal before the test begins.

ANS:ACaffeine-containing liquids and foods are central nervous system stimulants and may alter the test results. No contrast is used; therefore the client does not need to increase fluid intake. The test does not require MRI, so metal does not have to be removed. The client should take cardiac medications as prescribed.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Health Promotion and Maintenance (Health Screening)MSC:Integrated Process: Nursing Process (Planning)

18.A female client with deteriorating neurologic function states, I am worried I will not be able to care for my young children. How does the nurse respond?a.Caring for your children is a priority. You may not want to ask for help, but you have to.b.Our community has resources that may help you with some household tasks so you have energy to care for your children.c.You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?d.Give me more information about what worries you, so we can see if we can do something to make adjustments.

ANS:DInvestigate specific concerns about situational or role changes before providing additional information. The nurse should tell the client what is or is not a priority for her. Although community resources may be available, they may not be appropriate for the client. Consulting a psychologist would not be appropriate.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Psychosocial Integrity (Therapeutic Communication)MSC:Integrated Process: Communication and Documentation

19.The nurse is planning care for an 83-year-old client with age-related changes to his sensory perception. Which nursing action does the nurse implement to ensure the clients safety?a.Provide a call button that requires only minimal pressure to activate.b.Use a clock and a calendar to orient and minimize onset of dementia.c.Ensure that the path to the bathroom is free from equipment.d.Admit the client to the room closest to the nursing station.

ANS:CDementia and confusion are not common phenomena in older adults. However, physical impairment related to illness can be expected. Providing opportunities for hazard-free ambulation will maintain strength and mobility (and ensure safety). The other actions are not a priority.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Basic Care and ComfortMobility/Immobility)MSC:Integrated Process: Nursing Process (Implementation)

20.A client is scheduled for a single-photon emission computed tomography test. Which condition in the clients history causes the nurse to contact the provider before the test takes place?a.Peptic ulcersb.Smoking historyc.Liver failured.Currently breast feeding

ANS:DA SPECT test uses radiopharmaceutical agents that enable radioisotopes to cross the blood-brain barrier. This test is contraindicated in women who are breast-feeding. Having a history of smoking, peptic ulcers, or liver failure should not interfere with the client having this test.


21.The nurse is teaching a client before magnetic resonance imaging (MRI). Which statement indicates that the client understands the content of the education?a.I need to stay away from heavy metals for the next 48 hours.b.My urine will be radioactive for the next 48 hours.c.I must increase my fluids because of the dye used for the MRI.d.I can return to my usual activities immediately after the MRI.

ANS:DNo postprocedure restrictions are imposed after MRI. The client can return to normal activities after the test is complete.


22.While assessing pain discrimination, a client correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. How does the nurse then proceed with the examination?a.Touch the pin on the same area of the left hand.b.Touch the pin on the right forearm.c.Touch the pin on the right upper arm.d.Touch the right hand with a drop of cold water.

ANS:AIf testing is begun on the hand and the client correctly identifies the pain stimulus, testing more proximal parts of that extremity is not necessary because, if the distal tract is intact, so are the proximal areas. Temperature discrimination is not necessary because the same tract transmits both pain and temperature sensation.

DIF:Cognitive Level: Comprehension/UnderstandingREF:p. 915TOP:Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-Specific Assessments)MSC:Integrated Process: Nursing Process (Assessment)

23.The nurse is assessing a client scheduled for a lumbar puncture. Which clinical manifestation assessed by the nurse complicates the lumbar puncture procedure?a.Normal intracranial pressuresb.Allergy to iodine or shellfishc.Restlessness and agitationd.Eating lunch less than 2 hours ago

ANS:CClients must be able to hold still during the procedure. If a client is restless or agitated, assistance may be needed to ensure that the procedure is completed safely. Lumbar puncture is not performed on clients with severely high intracranial pressure. Allergies to iodine and shellfish or eating lunch 2 hours before the procedure have no effect on the procedure.

DIF:Cognitive Level: Comprehension/UnderstandingREF:p. 925TOP:Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests/Treatments/Procedures)MSC:Integrated Process: Nursing Process (Assessment)

24.On assessment of the left plantar reflexes of an adult client, the nurse notes the response shown in the photograph below. What action does the nurse take after assessing this new finding?

a.Relay this abnormal finding to other members of the health care team.b.Anticipate the need for cerebral angiography to determine the cause.c.Examine the family history for a potential genetic disorder.d.Document the finding and continue the assessment.

ANS:AThis finding is a positive Babinski reflex. In clients older than 2 years of age, a positive Babinski reflex is considered abnormal and indicates central nervous system disease. The nurse should notify the health care provider and other members of the health care team because further investigation is warranted.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Physiological Adaptation-Pathophysiology)MSC:Integrated Process: Nursing Process (Implementation)

MULTIPLE RESPONSE

1.In a client with an injury to the medulla, the nurse monitors for which clinical manifestations secondary to damage of cranial nerves that emerge from the medulla? (Select all that apply.)a.Loss of smellb.Impaired swallowingc.Blink reflexd.Visual changese.Inability to shrug shouldersf.Loss of gag reflex

ANS:B, E, FCranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal) emerge from the medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic). Damage to these nerves causes impaired swallowing, inability to shrug shoulders, and loss of the gag reflex. The other manifestations are not associated with damage to the medulla.


2.The nurse is assessing a client with a temporal lobe injury. Which clinical manifestations correlate with this injury? (Select all that apply.)a.Memory lossb.Personality changesc.Loss of temperature regulationd.Difficulty with sound interpretatione.Speech difficultiesf.Impaired taste

ANS:A, D, EWernickes area (language area) is located in the temporal lobe and enables processing of words into coherent thought and understanding of written or spoken words. The temporal lobe also is responsible for the auditory centers interpretation of sound and complicated memory patterns. Personality changes are related to damage to frontal lobe injury. Loss of temperature regulation is seen with damage to the hypothalamus, and impaired taste is associated with injury to the parietal lobe.


3.The nurse is administering a medication to a client that stimulates the sympathetic division of the autonomic nervous system. Which clinical manifestations does the nurse monitor for? (Select all that apply.)a.Decreased heart rateb.Increased heart ratec.Decreased force of contractiond.Increased force of contractione.Decreased respirations

ANS:B, DStimulation of the sympathetic nervous system initiates the fight-or-flight response, increasing both the heart rate and the force of contraction. The other three options do not occur with sympathetic nervous system stimulation.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)MSC:Integrated Process: Nursing Process (Assessment)

COMPLETION

1.Immediately after a lumbar puncture, the client begins to vomit and an IV is started with normal saline (0.9% NS). The provider orders a 200-mL bolus over 15 minutes. Using an infusion pump that delivers mL/hr, the rate at which the nurse sets the pump is _____ mL.

ANS:800200 mL/15 min = x mL/60 min200 mL/15 min = 800 mL/60 min15x = 12,000x = 800 mL

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesDosage Calculation)MSC:Integrated Process: Nursing Process (Implementation)

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