NEURO assessment

18. The nurse is preparing to assess an older patient's neurologic status. What should the nurse keep in mind during this assessment? 1) Reaction time is slower 2) Flexibility is maintained 3) Pain sensation is heightened 4) Body movements are quicker 18.

ANS: 1 Feedback 1 An age-related change to the neurologic system includes decreased reaction time. 2 Flexibility is decreased in an older patient. 3 Pain sensations are decreased in an older patient. 4 Body movements are slower in an older patient.

9. A patient is unable to feel light touch down the anterior left leg and top of the left foot. How should the nurse document this finding? 1) Anesthesia 2) Paresthesia 3) Hypoesthesia 4) Hyperesthesia 9.

ANS: 1 Feedback 1 Anesthesia is the absence of sensation. 2 Paresthesia is an abnormal feeling of pins and needles, itching, numbness, and tingling. 3 Hypoesthesia is a decreased feeling to touch; numbness. 4 Hyperesthesia is an increased sensitivity to touch.

4. A patient reports a change in the taste of food. Which cranial nerve should the nurse suspect as being affected? 1) CN VII Facial 2) CN V Trigeminal 3) CN XI Accessory 4) CN XII Hypoglossal 4.

ANS: 1 Feedback 1 CN VII Facial influences taste. 2 CN V Trigeminal controls touch, temperature, pain sensations from the upper and lower face, and chewing. 3 CN XI Accessory controls swallowing and head, neck, and shoulder movements. 4 CN XII Hypoglossal controls tongue movement with speech, food manipulation, and swallowing.

8. Which technique should the nurse use to assess a patient's CN IX Glossopharyngeal? 1) Apply a tongue depressor to the back of the throat 2) Ask the patient to read from a book or a newspaper 3) Ask the patient to smile, frown, puff cheeks, and raise eyebrows 4) Ask the patient to follow the examiner's finger as it is moved toward the patient's nose 8.

ANS: 1 Feedback 1 CN XI Glossopharyngeal is assessed by applying a tongue depressor to the back of the throat to check for a gag reflex. 2 Reading assesses CN II Optic. 3 Smiling, frowning, puffing out the cheeks, and raising the eyebrows assesses CN VII Facial. 4 Having the patient follow a finger as it is moved toward the nose assesses CN IV Trochlear.

19. The nurse notes that an older patient sways when moving from a sitting to a standing position. What is this patient at risk for experiencing? 1) Falls 2) Hypothermia 3) Altered pain sensation 4) Reduced oxygen to the brain 19.

ANS: 1 Feedback 1 Instability when moving from a sitting to a standing position increases this patient's risk of falling. 2 Instability when moving from a sitting to a standing position has no effect on temperature regulation. 3 Instability when moving from a sitting to a standing position has no effect on pain sensations. 4 Instability when moving from a sitting to a standing position has no effect on cerebral oxygenation.

13. During a neurologic assessment the nurse asks a patient to close the eyes and asks the patient to identify a paper clip placed in the hand. What is the nurse assessing? 1) Stereognosis 2) Hyperesthesia 3) Graphesthesia 4) Two-point discrimination 13.

ANS: 1 Feedback 1 Stereognosis or the ability to identify an object by its shape by simply holding the object. 2 Hyperesthesia or an increased sensitivity to touch. 3 Graphesthesia or the ability to identify letters or numbers when drawn on the skin. 4 Two-point discrimination is the ability to distinguish two points separately.

10. A patient is scheduled for a positron emission tomography (PET) scan. For which health problem should the nurse anticipate planning care for this patient? 1) Brain tumor 2) Cerebral bleed 3) Cranial fracture 4) Cerebral blood clot 10.

ANS: 1 Feedback 1 The PET scan is a very sensitive test for detecting cancer because rapidly dividing cancer cells absorb the tracer, making them detectable with the scanner. 2 A PET scan is not used to diagnose a cerebral bleed. 3 A PET scan is not used to diagnose or identify a cranial fracture. 4 A PET scan is not used to diagnose a cerebral blood clot

12. The nurse notes that a patient has ataxia. Which test should the nurse use to gain more information about this patient's gait? 1) Romberg 2) Patellar reflex 3) Plantar flexion 4) Achilles reflex 12.

ANS: 1 Feedback 1 The Romberg test is performed to assess balance. 2 Reflexes are involuntary and automatic responses to stimuli that provide the body with protection and help to adjust to the environment. 3 Reflexes are involuntary and automatic responses to stimuli that provide the body with protection and help to adjust to the environment. 4 Reflexes are involuntary and automatic responses to stimuli that provide the body with protection and help to adjust to the environment.

3. A patient experiences a cramp in the right thigh. Which spinal tract is responsible for communicating to the thigh muscle to contract? 1) Somatic motor division 2) Visceral motor division 3) Somatic sensory division 4) Visceral sensory division 3.

ANS: 1 Feedback 1 The somatic motor division transports signals back to the skeletal muscles to produce a contraction. 2 The visceral motor division transports signals back to smooth muscle, cardiac muscle, and glands at an unconscious level. 3 The somatic sensory division transmits signals from receptors in muscles, bones, joints, and skin. 4 The visceral sensory division transmits signals from the heart, lungs, GI tract, and bladder.

24. The nurse notes that a patient has a positive Babinski response. For what should the nurse assess this patient? Select all that apply. 1) Alcohol abuse 2) Substance abuse 3) Multiple sclerosis 4) Parkinson's disease 5) Traumatic brain injury 24.

ANS: 1, 2, 3, 5 Feedback 1. A positive Babinski's can occur in patients with alcohol abuse. 2. A positive Babinski's can occur in patients with substance abuse. 3. A positive Babinski's can occur in patients with multiple sclerosis. 4. A positive Babinski's is not identified as occurring in patients with Parkinson's disease. 5. A positive Babinski's can occur in patients with traumatic brain injury.

21. The nurse is preparing a teaching tool about the nervous system. Which type of tissue should the nurse identify as being a part of gray matter? Select all that apply. 1) Dendrites 2) Cell bodies 3) Myelin sheath 4) Axon terminals 5) Nodes of Ranvier 21.

ANS: 1, 2, 4 Feedback 1. Gray matter contains dendrites. 2. Gray matter contains cell bodies. 3. White matter contains myelin sheaths. 4. Gray matter contains axon terminals. 5. White matter contains the Nodes of Ranvier.

25. A patient is recovering from a cerebral angiogram. What care should the nurse provide to this patient? Select all that apply. 1) Monitor intravenous fluid infusion 2) Elevate the puncture site limb on a pillow 3) Maintain pressure on arterial puncture site 4) Enforce bedrest for 6 to 12 hours after the procedure 5) Monitor vital signs every 15 minutes for the first hour 25.

ANS: 1, 3, 4, 5 Feedback 1. After a cerebral angiogram intravenous fluids are needed to clear contrast dye from the circulation. 2. The limb used for the puncture site should be kept straight for 6 to 12 hours. 3. Pressure should be maintained on the puncture site. 4. The patient should be on bedrest for 6 to 12 hours after the procedure. 5. Vital signs should be monitored every 15 minutes for the first hour.

7. The nurse is completing a Mini Mental Status Examination with a patient. What should the nurse ask to evaluate remote memory? 1) "Where did you park your car?" 2) "Where did you work in the 1970s?" 3) "Remember the colors red, green, blue, and yellow." 4) "What television show was on this morning during breakfast?" 7.

ANS: 2 Feedback 1 "Where did you park your car" assesses recent memory. 2 "Where did you work in the 1970s" assesses remote memory. 3 Asking the patient to remember colors assesses immediate memory. 4 "What television show was on this morning during breakfast" assesses recent memory.

11. A patient has been experiencing numbness of the right hand. Which diagnostic test should the nurse anticipate being prescribed for this patient? 1) Myelogram 2) Evoked potentials 3) Electroencephalography 4) Magnetic resonance imaging 11.

ANS: 2 Feedback 1 A myelogram enables visualization of the entire spinal column to evaluate for lesions, cysts, injury, herniated discs, and tumors. 2 A somatosensory evoked potential focuses on nerve conduction in the arms and legs and is done with mild electrical stimulation. Somatosensory evoked potential electrodes are typically placed on the wrist (medial nerve). 3 Electroencephalography is a diagnostic test for epilepsy and other electrical activity abnormalities. 4 An MRI can be used to assess injuries of the brain and spinal column—diagnose tumors, infections, and bleeding. It is very useful in the diagnosis of a cerebrovascular accident (CVA) or stroke.

5. A patient's blood pressure increases after hearing that diagnostic tests for a health problem have to be repeated. Which receptor of the sympathetic nervous system is responsible for this blood pressure change? 1) Beta 2) Alpha 3) Nicotinic 4) Muscarinic 5.

ANS: 2 Feedback 1 Beta receptors are usually inhibitory and dilate bronchioles, which enhances airflow. Beta receptors can also have excitatory effects on cardiac muscle, producing a stronger cardiac contraction and increased heart rate. 2 Alpha receptors typically have an excitatory effect, producing vasoconstriction that increases blood pressure. 3 Nicotinic receptors are part of the parasympathetic nervous system and have an excitatory effect. 4 Muscarinic receptors are part of the parasympathetic nervous system and have an excitatory or inhibitory response depending on the target organ system.

6. The nurse needs to provide a strong stimulus to illicit a response; however, the patient drifts back to unresponsiveness. What term should the nurse use to document this patient's level of responsiveness? 1) Coma 2) Stupor 3) Lethargic 4) Conscious 6.

ANS: 2 Feedback 1 Coma means the patient is unarousable and unresponsive. 2 Stupor is defined as having minimal movement without stimulus; requires strong vigorous stimulus and then drifts back to unresponsiveness. 3 Lethargic means the patient is severely sleepy and has a slow and delayed response to stimulus. 4 Conscious means the patient is awake with appropriate speech and behavior.

15. A patient is scheduled for an electroencephalogram. What preprocedure information should the nurse emphasize with this patient? 1) Avoid washing hair for two days prior to the test 2) Avoid caffeine for 8 to 12 hours before the test 3) Restrict the intake of fluids for six hours after the test 4) Apply minimal products to the hair the morning of the test 15.

ANS: 2 Feedback 1 The hair should be washed the night before and the morning of the test. 2 Caffeine should be avoided for 8 to 12 hours before the test because caffeine may alter the results. 3 Fluids do not need to be restricted for this test. 4 Hair products should be avoided prior to the test to aid in scalp electrode attachment.

17. A patient is scheduled for a myelogram prior to having spinal fusion surgery. What should the nurse instruct the patient to do prior to this test? 1) Shower with antiseptic soap 2) Take nothing by mouth for four hours before the test 3) Take an over-the-counter analgesic before arriving for the test 4) Restrict the intake of caffeine products for 24 hours before the test 17.

ANS: 2 Feedback 1 The patient does not need to shower with antiseptic soap before the test. 2 For a myelogram the patient should be instructed to take nothing by mouth for four hours before the test. 3 The patient should not take anything by mouth for four hours before the test. 4 Caffeine products do not need to be restricted for this test.

2. A patient is experiencing changes in eye movements. Which part of the central nervous system is most likely causing these changes? 1) Pons 2) Midbrain 3) Medulla oblongata 4) Reticular formation 2.

ANS: 2 Feedback 1 The pons rests above the medulla oblongata below and anterior to the midbrain, and relays all impulses between the brain and the spinal cord. Four cranial nerves originate in the pons: trigeminal (V), abducens (V), facial (VII), and acoustic (VIII). 2 The midbrain contains the nerve pathways between the cerebrum and the medulla oblongata. Cranial nerves III and IV, which control eye movements, have their origins here. 3 The medulla oblongata is continuous with the spinal cord and is located at the level of and below the foramen magnum. Four cranial nerves originate here: glossopharyngeal (IX), vagus (X), spinal accessory (XI), and hypoglossal (XII). 4 The reticular formation consists of networks of neural cells that impact motor control and coordination, balance and posture during movement, respiratory and cardiac functions, pain modulation, and alertness and sleep.

22. A patient sustains an injury to the left temporal lobe. Which body functions should the nurse expect to be affected by this injury? Select all that apply. 1) Body position 2) Long-term memory 3) Auditory perception 4) Receptive speech center 5) Expressive speech center 22.

ANS: 2, 3, 4 Feedback 1. Body position is a function of the parietal lobe. 2. Long-term memory is a function of the temporal lobe. 3. Auditory perception is a function of the temporal lobe. 4. Receptive speech is a function of the temporal lobe. 5. Expressive speech is a function of the frontal lobe.

23. The nurse is conducting a medical history with a patient experiencing headaches. Which information should be included in this history? Select all that apply. 1) Date of last lipid screen 2) Past surgical procedures 3) Recent diagnostic studies 4) Treatment for chronic illnesses 5) Date of last influenza vaccination 23.

ANS: 2, 3, 4 Feedback 1. Lipid screen information would be included under regular medical care. 2. Medical history includes past surgical procedure/treatments. 3. Medical history includes recent diagnostic studies. 4. Medical history includes treatment for chronic diseases. 5. Date of last influenza vaccination would be included under regular medical care.

1. A patient is diagnosed with a health problem that causes demyelization of the peripheral nerves. Which cell structure is being affected? 1) Microglia 2) Astrocytes 3) Schwann cells 4) Oligodendrocytes 1.

ANS: 3 Feedback 1 Microglia are small cells that become phagocytic when they encounter inflammation or debris. They are a means of defense. 2 Astrocytes provide structure and support. 3 Schwann cells form myelin sheaths that cover axons in the peripheral nervous system. 4 Oligodendrocytes are small cells that form myelin sheaths that cover the axons of the neurons in the central nervous system.

16. A patient recovering from a lumbar puncture rates a headache as being 8 on a pain scale of 0 to 10. What should the nurse do while waiting for the health-care provider to prescribe pain medication? 1) Raise the head of the bed 2) Assist to sit out of bed in a chair 3) Encourage increasing oral fluid intake 4) Turn on the side and massage the lower spine 16.

ANS: 3 Feedback 1 The bed should be flat to prevent the onset or worsening of a headache. 2 The patient should be on bedrest for four to six hours. 3 To avoid postlumbar puncture headaches, ask the patient to stay hydrated postprocedure. 4 Massaging the lower spine will not help reduce a spinal headache.

20. Family members are concerned because a patient has been confused over the last few days. What should the nurse respond to the family? 1) "Confusion is a normal sign of aging." 2) "Older people get confused at the end of the day." 3) "Unless the patient falls, there is nothing to worry about." 4) "Confusion can mean many things that should be evaluated." 20.

ANS: 4 Feedback 1 Caution should be taken in assuming that confusion is a "normal" part of aging, as this change can also occur as a result of disease or an infection. 2 There is no evidence to support that older people get confused at the end of the day. 3 Confusion should be investigated. The patient should not have to wait until a fall occurs to be evaluated for confusion. 4 Cognitive impairment can occur as a result of the aging process, disease, medications, poor nutrition, and changes in the nervous system.

14. A patient with type 2 diabetes mellitus is scheduled for a CT scan with contrast. What should the nurse specifically instruct the patient to prepare for this test? 1) Restrict fluids for 12 hours prior to the scan 2) Drink two liters of fluid the day before the scan 3) Limit the intake of meat and dairy products prior to the scan 4) Do not take Metformin for 48 hours prior to and after the scan 14.

ANS: 4 Feedback 1 Fluids do not need to be restricted prior to a CT scan with contrast. 2 Fluids do not need to be increased prior to a CT scan with contrast. 3 Meat and dairy products do not need to be restricted prior to a CT scan with contrast. 4 Metformin is cleared primarily through the kidneys, and if it is administered prior to the examination and the administration of contrast results in renal impairment, metformin levels will remain elevated, potentially resulting in a lactic acidosis. Because of this metformin must be held 48 hours prior to and after the CT scan or until renal function is determined to be normal via normal BUN and creatinine levels.

18. A nurse prepares a client for lumbar puncture (LP). Which assessment finding should alert the nurse to contact the health care provider? a. Shingles on the clients back b. Client is claustrophobic c. Absence of intravenous access d. Paroxysmal nocturnal dyspnea

ANS: A An LP should not be performed if the client has a skin infection at or near the puncture site because of the risk of infection. A nurse would want to notify the health care provider if shingles were identified on the clients back. If a client has shortness of breath when lying flat, the LP can be adapted to meet the clients needs. Claustrophobia, absence of IV access, and paroxysmal nocturnal dyspnea have no impact on whether an LP can be performed. DIF: Applying/Application REF: 859 KEY: Assessment/diagnostic examination| interdisciplinary team| communication MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

9. A patient has a tumor in the cerebellum. What goal should the nurse use to focus the plan of care? a. Prevent falls. b. Stabilize mood. c. Avoid aspiration. d. Improve memory.

ANS: A Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

11. A nurse teaches a client who is scheduled for a positron emission tomography scan of the brain. Which statement should the nurse include in this clients teaching? a. Avoid caffeine-containing substances for 12 hours before the test. b. Drink at least 3 liters of fluid during the first 24 hours after the test. c. Do not take your cardiac medication the morning of the test. d. Remove your dentures and any metal before the test begins.

ANS: A Caffeine-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 client should take cardiac medications as prescribed. Metal does not have to be removed; this is done for magnetic resonance imaging. DIF: Applying/Application REF: 856 KEY: Assessment/diagnostic examination MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

7. A nurse assesses a client recovering from a cerebral angiography via the clients right femoral artery. Which assessment should the nurse complete? a. Palpate bilateral lower extremity pulses. b. Obtain orthostatic blood pressure readings. c. Perform a funduscopic examination. d. Assess the gag reflex prior to eating.

ANS: A Cerebral 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 readings 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: Applying/Application REF: 855 KEY: Assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

17. A nurse delegates care to the unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating care for a client with cranial nerve II impairment? a. Tell the client where food items are on the breakfast tray. b. Place the client in a high-Fowlers position for all meals. c. Make sure the clients food is visually appetizing. d. Assist the client by placing the fork in the left hand.

ANS: A Cranial nerve II, the optic nerve, provides central and peripheral vision. A client who has cranial nerve II impairment will not be able to see, so the UAP should tell the client where different food items are on the meal tray. The other options are not appropriate for a client with cranial nerve II impairment. DIF: Applying/Application REF: 845 KEY: Brain trauma/injury/tumor| delegation| unlicensed assistive personnel (UAP) MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

15. A nurse performs an assessment of pain discrimination on an older adult client. The client correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action should the nurse take next? a. Touch the pin on the same area of the left hand. b. Contact the provider with the assessment results. c. Ask the client about current medications. d. Continue the assessment on the clients feet.

ANS: A If testing is begun on the right hand and the client correctly identifies the pain stimulus, the nurse should continue the assessment on the left hand. This is a normal finding and does not need to be reported to the provider, but instead documented in the clients chart. Medications do not need to be assessed in response to this finding. The nurse should assess the left hand prior to assessing the feet. DIF: Understanding/Comprehension REF: 852 KEY: Assessment/diagnostic examination| motor/sensory impairment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Health Promotion and Maintenance

21. A nurse assesses a client and notes the clients position as indicated in the illustration below: How should the nurse document this finding? a. Decorticate posturing b. Decerebrate posturing c. Atypical hyperreflexia d. Spinal cord degeneration

ANS: A The 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. Hyperreflexes present as increased reflex responses. Spinal cord degeneration presents frequently with pain and discomfort. DIF: Applying/Application REF: 851 KEY: Assessment/diagnostic examination MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

20. A nurse cares for a client who is recovering from a single-photon emission computed tomography (SPECT) with a radiopharmaceutical agent. Which statement should the nurse include when discussing the plan of care with this client? a. You may return to your previous activity level immediately. b. You are radioactive and must use a private bathroom. c. Frequent assessments of the injection site will be completed. d. We will be monitoring your renal functions closely.

ANS: A The client may return to his or her previous activity level immediately. Radioisotopes will be eliminated in the urine after SPECT, but no monitoring or special precautions are required. The injection site will not need to be assessed after the procedure is complete. DIF: Applying/Application REF: 856 KEY: Assessment/diagnostic examination| patient education MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

5. A nurse assesses a client who 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 proprioception b. Peripheral motor disorder c. Impaired cerebellar function d. Positive pronator drift

ANS: A The 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 describe a positive Rombergs sign. DIF: Applying/Application REF: 852 KEY: Motor/sensory impairment MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

22. A nurse assesses the left plantar reflexes of an adult client and notes the response shown in the photograph below: Which action should the nurse take next? a. Contact the provider with this abnormal finding. b. Assess bilateral legs for temperature and edema. c. Ask the client about pain in the lower leg and calf. d. Document the finding and continue the assessment.

ANS: A This finding indicates Babinskis sign. In clients older than 2 years of age, Babinskis sign 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. This finding does not relate to perfusion of the leg or to pain. This is an abnormal assessment finding and should be addressed immediately. DIF: Applying/Application REF: 851 KEY: Assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

1. When admitting an acutely confused patient with a head injury, which action should the nurse take? a. Ask family members about the patient's health history. b. Ask leading questions to assist in obtaining health data. c. Wait until the patient is better oriented to ask questions. d. Obtain only the physiologic neurologic assessment data.

ANS: A When admitting a patient who is likely to be a poor historian, the nurse should obtain health history information from others who have knowledge about the patient's health. Waiting until the patient is oriented or obtaining only physiologic data will result in incomplete assessment data, which could adversely affect decision making about treatment. Asking leading questions may result in inaccurate or incomplete information. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

5. A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodine-based contrast. Which actions should the nurse take to prepare the client for this procedure? (Select all that apply.) a. Ensure that an informed consent is present. b. Ask the client about any allergies. c. Evaluate the clients renal function. d. Auscultate bilateral breath sounds. e. Assess hematocrit and hemoglobin levels.

ANS: A, B, C A client who is scheduled to receive iodine-based contrast should be asked about allergies, especially allergies to iodine or shellfish. The clients kidney function should also be evaluated to determine if it is safe to administer contrast during the procedure. Finally, the nurse should ensure that an informed consent is present because all clients receiving iodine-based contrast must give consent. The CT will have no impact on the clients breath sounds or hematocrit and hemoglobin levels. Findings from these assessments will not influence the clients safety during the procedure. DIF: Understanding/Comprehension REF: 855 KEY: Assessment/diagnostic examination| allergies MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

7. A nurse delegates care for an older adult client to the unlicensed assistive personnel (UAP). Which statements should the nurse include when delegating this clients care? (Select all that apply.) a. Plan to bathe the client in the evening when the client is most alert. b. Encourage the client to use a cane when ambulating. c. Assess the client for symptoms related to pain and discomfort. d. Remind the client to look at foot placement when walking. e. Schedule additional time for teaching about prescribed therapies.

ANS: A, B, D The nurse should tell the UAP to schedule activities when the client is normally awake, encourage the client to use a cane when ambulating, and remind the client to look where feet are placed when walking. The nurse should assess the client for symptoms of pain and should provide sufficient time for older adults to process information, including new teaching. These are not items the nurse can delegate. DIF: Applying/Application REF: 846 KEY: Older adult| delegation| unlicensed assistive personnel (UAP) MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 352

4. A nurse assesses a client with a brain tumor. Which newly identified assessment findings should alert the nurse to urgently communicate with the health care provider? (Select all that apply.) a. Glasgow Coma Scale score of 8 b. Decerebrate posturing c. Reactive pupils d. Uninhibited speech e. Diminished cognition

ANS: A, B, E The nurse should urgently communicate changes in a clients neurologic status, including a decrease in the Glasgow Coma Scale score, abnormal flexion or extension, changes in cognition or speech, and pinpointed, dilated, and nonreactive pupils. DIF: Applying/Application REF: 854 KEY: Brain trauma/injury/tumor MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

2. An emergency department nurse assesses a client who was struck in the temporal lobe with a baseball. For which clinical manifestations that are related to a temporal lobe injury should the nurse assess? (Select all that apply.) a. Memory loss b. Personality changes c. Difficulty with sound interpretation d. Speech difficulties e. Impaired taste

ANS: A, C, D Wernickes area (language area) is located in the temporal lobe and enables the processing of words into coherent thought as well as the 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 frontal lobe injury. Impaired taste is associated with injury to the parietal lobe. DIF: Remembering/Knowledge REF: 841 KEY: Brain trauma/injury/tumor| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

16. A 39-yr-old patient with a suspected herniated intervertebral disc is scheduled for a myelogram. Which information communicated by the nurse to the health care provider before the procedure would change the procedural plans? a. The patient is anxious about the test results. b. The patient reports a previous allergy to shellfish. c. The patient has back pain when lying flat for more than 4 hours. d. The patient drank apple juice 4 hours before the scheduled procedure.

ANS: B A contrast medium containing iodine is injected into the subarachnoid space during a myelogram. The patient's allergy would contraindicate the use of this medium. The health care provider may need to provide orders to treat back pain after the procedure. Clear liquids are usually considered safe up to 4 hours before a diagnostic or surgical procedure. The patient's anxiety should be addressed, but procedural plans would not need to be changed. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

10. Which problem should the nurse expect for a patient who has a positive Romberg test result? a. Pain b. Falls c. Aphasia d. Confusion

ANS: B A positive Romberg test result indicates that the patient has difficulty maintaining balance when standing with the eyes closed. The Romberg test does not assess orientation, thermoregulation, or discomfort. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

6. An unconscious male patient has just arrived in the emergency department with a head injury caused by a motorcycle crash. Which planned intervention by the health care provider should the nurse question? a. Obtain x-rays of the skull and spine. b. Prepare the patient for lumbar puncture. c. Send for computed tomography (CT) scan. d. Perform neurologic checks every 15 minutes.

ANS: B After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure. Herniation of the brain could result if lumbar puncture is performed. The other orders are appropriate. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

8. A nurse obtains a focused health history for a client who is scheduled for magnetic resonance angiography. Which priority question should the nurse ask before the test? a. Have you had a recent blood transfusion? b. Do you have allergies to iodine or shellfish? c. Are you taking any cardiac medications? d. Do you currently use oral contraceptives?

ANS: B Allergies 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. A recent blood transfusion or current use of cardiac medications or oral contraceptives would not affect the angiography. DIF: Applying/Application REF: 855 KEY: Assessment/diagnostic examination| allergies MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

13. Which information about a 76-yr-old patient should the nurse identify as uncharacteristic of normal aging? a. Triceps reflex response graded at 1/5 b. Unintended weight loss of 15 pounds c. Patient report of chronic difficulty in falling asleep d. 10 mm Hg orthostatic drop in systolic blood pressure

ANS: B Although changes in appetite are normal with aging, a 15-pound weight loss requires further investigation. Orthostatic drops in blood pressure, changes in sleep patterns, and slowing of reflexes are normal changes in aging. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

18. Several patients have been hospitalized for diagnosis of neurologic problems. Which patient should the nurse assess first? a. A patient with a transient ischemic attack (TIA) returning from carotid duplex studies b. A patient with a brain tumor who has just arrived on the unit after a cerebral angiogram c. A patient with a seizure disorder who has just completed an electroencephalogram (EEG) d. A patient prepared for a lumbar puncture whose health care provider is waiting for assistance

ANS: B Because cerebral angiograms require insertion of a catheter into the femoral artery, bleeding is a possible complication. The nurse will need to check the pulse and blood pressure and assess the catheter insertion site in the groin as soon as the patient arrives. Carotid duplex studies and EEG are noninvasive. The nurse will need to assist with the lumbar puncture as soon as possible but monitoring for hemorrhage after cerebral angiogram has a higher priority. DIF: Cognitive Level: Analyze (analysis) OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

2. Which finding should the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion? a. Spasticity b. Flaccidity c. Impaired sensation d. Hyperactive reflexes

ANS: B Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor neuron lesions. DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. A nurse plans care for a client who has a hypoactive response to a test of deep tendon reflexes. Which intervention should the nurse include in this clients plan of care? a. Check bath water temperature with a thermometer. b. Provide the client with assistance when ambulating. c. Place elastic support hose on the clients legs. d. Assess the clients feet for wounds each shift.

ANS: B Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. The nurse should plan to provide the client with ambulation assistance to prevent injury. The other interventions do not address the clients problem. DIF: Applying/Application REF: 848 KEY: Patient safety| motor/sensory impairment MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

5. Which action should the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)? a. Assist to stand and ambulate. b. Withhold oral fluids and food. c. Insert an oropharyngeal airway. d. Apply artificial tears every hour.

ANS: B The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. A patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve. Balance and coordination are cerebellar functions. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

19. A nurse assesses a client who is recovering from a lumbar puncture (LP). Which complication of this procedure should alert the nurse to urgently contact the health care provider? a. Weak pedal pulses b. Nausea and vomiting c. Increased thirst d. Hives on the chest

ANS: B The nurse should immediately contact the provider if the client experiences a severe headache, nausea, vomiting, photophobia, or a change in level of consciousness after an LP, which are all signs of increased intracranial pressure. Weak pedal pulses, increased thirst, and hives are not complications of an LP. DIF: Remembering/Knowledge REF: 841 KEY: Assessment/diagnostic examination| interdisciplinary team| communication MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

15. Which cerebrospinal fluid analysis result should the nurse recognize as abnormal and communicate to the health care provider? a. Specific gravity of 1.007 b. Protein of 65 mg/dL (0.65 g/L) c. Glucose of 45 mg/dL (1.7 mmol/L) d. White blood cell (WBC) count of 4 cells/L

ANS: B The protein level is high. The specific gravity, WBCs, and glucose values are normal. DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

12. Which equipment should the nurse obtain to assess vibration sense in a patient with diabetes who has peripheral nerve dysfunction? a. Sharp pin b. Tuning fork c. Reflex hammer d. Calibrated compass

ANS: B Vibration sense is testing by touching the patient with a vibrating tuning fork. The other equipment is needed for testing of pain sensation, reflexes, and two-point discrimination. DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

17. Which of the following should the nurse consider the priority nursing assessment for a patient being admitted with a brainstem infarction? a. Pupil reaction b. Respiratory rate c. Reflex reaction time d. Level of consciousness

ANS: B Vital centers that control respiration are located in the medulla and part of the brainstem. They require priority assessments because changes in respiratory function may be life threatening. The other information will also be obtained by the nurse but is not as urgent. DIF: Cognitive Level: Apply (application) OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

1. Which assessments should the nurse make to monitor a patient's cerebellar function? (Select all that apply.) a. Test for graphesthesia. b. Observe arm swing with gait. c. Perform the finger-to-nose test. d. Assess heat and cold sensation. e. Measure strength against resistance.

ANS: B, C The cerebellum is responsible for coordination and is assessed by looking at the patient's gait and the finger-to-nose test. The other assessments will be used for other parts of the neurologic assessment. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

3. After administering a medication that stimulates the sympathetic division of the autonomic nervous system, the nurse assesses the client. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Decreased respiratory rate b. Increased heart rate c. Decreased level of consciousness d. Increased force of contraction e. Decreased blood pressure

ANS: B, D Stimulation of the sympathetic nervous system initiates the fight-or-flight response, increasing both the heart rate and the force of contraction. A medication that stimulates the sympathetic nervous system would also increase the clients respiratory rate, blood pressure, and level of consciousness. Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 350 DIF: Applying/Application REF: 845 KEY: Medication safety| sympathetic medication MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

2. Which nursing actions should be included in the plan of care for a patient after cerebral angiography? (Select all that apply.) a. Monitor for photophobia. b. Observe for bleeding at the puncture site. c. Keep patient NPO until gag reflex returns. d. Check pulse and blood pressure frequently. e. Assess orientation to person, place, and time.

ANS: B, D, E Because a catheter is inserted into an artery (e.g., the femoral artery) during cerebral angiography, the nurse should assess for bleeding at the site and bleeding that may affect pulse and blood pressure. Neuro status should be assessed often. There is no reason to keep the patient NPO. Photophobia is not expected. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank

1. A nurse assesses a client with an injury to the medulla. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Loss of smell b. Impaired swallowing c. Visual changes d. Inability to shrug shoulders e. Loss of gag reflex

ANS: B, D, E Cranial 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. DIF: Applying/Application REF: 842 KEY: Brain trauma/injury/tumor| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

6. A nurse assesses an older client. Which assessment findings should the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.) a. Long-term memory loss b. Slower processing time c. Increased sensory perception d. Decreased risk for infection e. Change in sleep patterns

ANS: B, E Normal changes in the nervous system related to aging include recent memory loss, slower processing time, decreased sensory perception, an increased risk for infection, changes in sleep patterns, changes in perception of pain, and altered balance and/or decreased coordination. DIF: Remembering/Knowledge REF: 846 KEY: Aging| older adult Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 351 MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Health Promotion and Maintenance

16. A nurse is teaching a client with cerebellar function impairment. Which statement should the nurse include in this clients discharge teaching? a. Connect a light to flash when your door bell rings. b. Label your faucet knobs with hot and cold signs. c. Ask a friend to drive you to your follow-up appointments. d. Use a natural gas detector with an audible alarm.

ANS: C Cerebellar function enables the client to predict distance or gauge the speed with which one is approaching an object, control voluntary movement, maintain equilibrium, and shift from one skilled movement to another in an orderly sequence. A client who has cerebellar function impairment should not be driving. The client would not have difficulty hearing, distinguishing between hot and cold, or smelling. DIF: Applying/Application REF: 841 KEY: Brain trauma/injury/tumor MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

13. A nurse plans care for an 83-year-old client who is experiencing age-related sensory perception changes. Which intervention should the nurse include in this clients plan of care? a. Provide a call button that requires only minimal pressure to activate. b. Write the date on the clients white board to promote orientation. c. Ensure that the path to the bathroom is free from equipment. d. Encourage the client to season food to stimulate nutritional intake.

ANS: C Dementia 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). Providing a call button, providing the date, and seasoning food do not address the clients impaired sensory perception. DIF: Applying/Application REF: 850 KEY: Patient safety| fall prevention| older adult MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

8. During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurse's directions to move his hands and feet. What should the nurse suspect as a likely cause of these findings? a. Cerebellar injury b. A brainstem lesion c. Frontal lobe damage d. A temporal lobe lesion

ANS: C Expressive speech (ability to express the self in language) is controlled by Broca's area in the frontal lobe. The temporal lobe contains Wernicke's area, which is responsible for receptive speech (ability to understand language input). The cerebellum and brainstem do not affect higher cognitive functions such as speech. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

6. A nurse asks a client to take deep breaths during an electroencephalography. The client asks, Why are you asking me to do this? How should the nurse respond? a. Hyperventilation causes vascular dilation of cerebral arteries, which decreases electoral activity in the brain. b. Deep breathing helps you to relax and allows the electroencephalograph to obtain a better waveform. c. Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity. d. Deep breathing will help you to blow off carbon dioxide and decreases intracranial pressures.

ANS: C Hyperventilation 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 accurate. DIF: Applying/Application REF: 859 KEY: Assessment/diagnostic examination MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

9. A nurse is caring for a client with a history of renal insufficiency who is scheduled for a computed tomography scan of the head with contrast medium. Which priority intervention should the nurse implement? a. Educate the client about strict bedrest after the procedure. b. Place an indwelling urinary catheter to closely monitor output. c. Obtain a prescription for intravenous fluids. d. Contact the provider to cancel the procedure.

ANS: C If 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 require bedrest. Although urinary output should be monitored closely, there is no need for an indwelling urinary catheter. There is no need to cancel the procedure as long as actions are taken to protect the kidneys. DIF: Applying/Application REF: 857 KEY: Assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

14. After teaching a client who is scheduled for magnetic resonance imaging (MRI), the nurse assesses the clients understanding. Which client statement indicates a correct understanding of the teaching? a. I must increase my fluids because of the dye used for the MRI. b. My urine will be radioactive so I should not share a bathroom. c. I can return to my usual activities immediately after the MRI. d. My gag reflex will be tested before I can eat or drink anything.

ANS: C No post procedure restrictions are imposed after MRI. The client can return to normal activities after the test is complete. There are no dyes or radioactive materials used for the MRI; therefore, increased fluids are not needed and the clients urine would not be radioactive. The procedure does not impact the clients gag reflex. DIF: Applying/Application REF: 856 KEY: Assessment/diagnostic examination| patient education MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. A nurse teaches an 80-year-old client with diminished touch sensation. Which statement should the nurse include in this clients teaching? a. Place soft rugs in your bathroom to decrease pain in your feet. b. Bathe in warm water to increase your circulation. c. Look at the placement of your feet when walking. d. Walk barefoot to decrease pressure ulcers from your shoes.

ANS: C Older 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. Throw rugs can slip and increase fall risk. Bath water that is too warm places the client at risk for thermal injury. The client should wear sturdy shoes for ambulation. DIF: Applying/Application REF: 846 KEY: Patient safety| motor/sensory impairment MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

23. A nurse assesses a client with a brain tumor. The client opens his eyes when the nurse calls his name, mumbles in response to questions, and follows simple commands. How should the nurse document this clients assessment using the Glasgow Coma Scale shown below? a. 8 b. 10 c. 12 d. 14

ANS: C The client opens his eyes to speech (Eye opening: To sound = 3), mumbles in response to questions (Verbal response: Inappropriate words = 3), and follows simple commands (Motor response: Obeys commands = 6). Therefore, the clients Glasgow Coma Scale score is: 3 + 3 + 6 = 12. DIF: Applying/Application REF: 853 KEY: Assessment/diagnostic examination MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. What should the nurse include in a focused assessment of a patient's left posterior temporal lobe functions? a. Sensation on the left side of the body b. Reasoning and problem-solving ability c. Ability to understand written and oral language d. Voluntary movements on the right side of the body

ANS: C The posterior temporal lobe integrates the visual and auditory input for language comprehension. Reasoning and problem solving are functions of the anterior frontal lobe. Sensation on the left side of the body is located in the right postcentral gyrus. Voluntary movement on the right side is controlled in the left precentral gyrus. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

1. A nurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which action should the nurse take when providing education about newly prescribed medications to this client? a. Help the client identify each medication by its color. b. Provide written materials with large print size. c. Sit on the clients right side and speak into the right ear. d. Allow the client to use a white board to ask questions.

ANS: C The 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 into the right ear. The other interventions do not address the clients left temporal lobe damage. DIF: Applying/Application REF: 841 KEY: Patient education| brain trauma/injury/tumor MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Psychosocial Integrity

4. How should the nurse assess the patient's trigeminal and facial nerve function (CNs V and VII)? a. Check for unilateral eyelid droop. b. Shine a light into the patient's pupil. c. Touch a cotton wisp strand to the cornea. d. Have the patient read a magazine or book.

ANS: C The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to evaluate function of the oculomotor nerve. DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

14. The charge nurse is observing a new nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action by the new nurse indicates the need for further teaching about neurologic assessment? a. Tests for light touch before testing for pain. b. Has the patient close the eyes during testing. c. Asks the patient if the instrument feels sharp. d. Uses an irregular pattern to test for intact touch.

ANS: C When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate. DIF: Cognitive Level: Apply (application) OBJ: Special Questions: Delegation TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment

4. A nurse assesses a clients recent memory. Which client statement confirms that the clients remote memory is intact? a. A young girl wrapped in a shroud fell asleep on a bed of clouds. b. I was born on April 3, 1967, in Johnstown Community Hospital. c. Apple, chair, and pencil are the words you just stated. d. I ate oatmeal with wheat toast and orange juice for breakfast.

ANS: D Asking clients about recent events that can be verified, such as what the client ate for breakfast, assesses the clients recent memory. The clients ability to make up a rhyme tests not memory, but rather a higher level of cognition. Asking clients about certain facts from the past that can be verified assesses remote or long-term memory. Asking the client to repeat words assesses the clients immediate memory. DIF: Applying/Application REF: 849 KEY: Memory| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Health Promotion and Maintenance

7. A patient with suspected meningitis is scheduled for a lumbar puncture. What action should the nurse take before the procedure? a. Enforce NPO status for 4 hours. b. Transfer the patient to radiology. c. Administer a sedative medication. d. Help the patient to a lateral position.

ANS: D For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

12. A nurse cares for a client who is experiencing deteriorating neurologic functions. The client states, I am worried I will not be able to care for my young children. How should 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: D Investigate specific concerns about situational or role changes before providing additional information. The nurse should not tell the client what is or is not a priority for him or her. Although community resources may be available, they may not be appropriate for the client. Consulting a psychologist would not be appropriate without obtaining further information from the client related to current concerns. DIF: Applying/Application REF: 854 KEY: Patient-centered care| therapeutic communication MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Psychosocial Integrity

10. A nurse obtains a focused health history for a client who is scheduled for magnetic resonance imaging (MRI). Which condition should alert the nurse to contact the provider and cancel the procedure? a. Creatine phosphokinase (CPK) of 100 IU/L b. Atrioventricular graft c. Blood urea nitrogen (BUN) of 50 mg/dL d. Internal insulin pump

ANS: D Metal devices such as internal pumps, pacemakers, and prostheses interfere with the accuracy of the image and can become displaced by the magnetic force generated by an MRI procedure. An atrioventricular graft does not contain any metal. CPK and BUN levels have no impact on an MRI procedure. DIF: Understanding/Comprehension REF: 858 Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 345 KEY: Assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

11. Which test should the nurse anticipate discussing with a patient who has a possible seizure disorder? a. Cerebral angiography b. Evoked potential studies c. Electromyography (EMG) d. Electroencephalography (EEG)

ANS: D Seizure disorders are usually assessed using EEG testing. Evoked potential is used to diagnose problems with the visual or auditory systems. Cerebral angiography is used to diagnose vascular problems. EMG is used to evaluate electrical innervation to skeletal muscle. DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

Chapter 35: Assessment of Neurological Function Multiple Choice

Identify the choice that best completes the statement or answers the question.

Chapter 41: Assessment of the Nervous System

MULTIPLE CHOICE

Chapter 55: Assessment: Nervous System Harding: Lewis's Medical-Surgical Nursing, 11th Edition

MULTIPLE CHOICE