chapter 41

2) 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? 1. Shrug the shoulders and turn the head against resistance. 2. Stick out the tongue and move it from side to side. 3. Taste foods and distinguish sweet from sour. 4. Smell items with one nostril blocked and identify them correctly.

Answer: 1 Explanation: 1. Cranial nerve XI, the spinal accessory nerve, is tested by asking the patient to shrug the shoulders and turn the head against resistance.

25) During an assessment, a patient's tongue deviates markedly to the right side. What is the patient most likely exhibiting? 1. Abnormal hypoglossal nerve response 2. First cranial nerve (CN I) damage 3. Sluggish oculomotor response 4. Absence of the Homans sign

Answer: 1 Explanation: 1. Cranial nerve XII (hypoglossal) is tested by having the patient stick out the tongue. An abnormal finding is that the tongue deviates to either side.

29) A patient's reflexes are documented as being 3+. How should the nurse interpret this finding? 1. The patient's reflexes are weaker than normal. 2. The patient's reflexes are normal. 3. The patient's reflexes are stronger than normal. 4. The patient's reflexes are hyperactive.

Answer: 3 3. 3+ reflexes are stronger than normal.

23) A patient reports hearing noises when alone in a quiet room. What action should the nurse take? 1. Make sure the patient is referred to a psychiatrist. 2. Document that the patient has a mental illness. 3. Ask if the patient experiences any visual disturbances. 4. Explain to the patient that this is not unusual.

Answer: 3 3. Information about perception difficulties such as visual and/or auditory disturbances is an important part of the health history of the nervous system. The nervous system controls cognition and sensory function, which includes vision and auditory changes.

14) 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? 1. Electroencephalogram (EEG) 2. Computed tomography (CT) 3. Evoked potentials 4. Electromyogram (EMG)

Answer: 1 Explanation: 1. An electroencephalogram (EEG) is part of the brain death protocol in hospitals. It measures the electrical activity of the brain and can also be used to diagnose brain disease.

20) The family of a patient recovering from a stroke asks what damage to "Broca's area" means. Which is the best response by the nurse? 1. "The way you communicate will have to change." 2. "You'll have to speak very loudly when you talk." 3. "Make sure there are no obstacles in the room, because sight will be a problem." 4. "Perhaps you would like to learn how to provide range-of-motion exercises."

Answer: 1 Explanation: 1. Broca's area in the cerebrum promotes the vocalization of words.

28) The nurse is conducting a health history with a patient exhibiting signs of Parkinson disease. Which question should the nurse ask the patient? 1. "Do you recall if any of your relatives had difficulty holding on to things with their hands?" 2. "Do you remember what you ate for breakfast this morning?" 3. "Is it painful to flex your chin to your chest?" 4. "Did your muscle weakness first occur in your arms or in your legs?"

Answer: 1 Explanation: 1. In Parkinson disease (PD), the lack of dopamine production leads to difficulty with movement, tremor, rigidity, and difficulty maintaining posture. It is thought that the disease process results from a complex interaction between genetic and environmental factors.

7) The nurse asks the patient to walk heel-to-toe, on the toes, and then on the heels. What function is the nurse assessing? 1. Cerebellar 2. Cerebral 3. Midbrain 4. Brainstem

Answer: 1 Explanation: 1. The ability to follow the instructions, walk heel-to-toe, on the toes, then on the heels provides information about the cerebellum.

10) The patient has lower motor neuron injuries. What type of reflexes should the nurse expect to assess in this patient? 1. Decreased 2. Increased 3. Normal 4. Exaggerated

Answer: 1 Explanation: 1. The finding of abnormally decreased reflexes points to disorders or diseases involving lower motor neuron impairment.

18) The nurse is conducting a seminar on Alzheimer disease (AD) with a group of community members. How should the nurse describe this health problem? Select all that apply. 1. The incidence of AD increases with age. 2. AD tends to run in families. 3. AD is more common in men. 4. AD is caused by a virus. 5. AD is caused by environmental contaminants.

Answer: 1, 2 Explanation: 1. The incidence of AD does tend to increase with age. 2. AD is thought to have a familial link.

36) An older patient is diagnosed with a new onset of a seizure disorder. What should the nurse recall when planning care for this patient? Select all that apply. 1. Commonly caused by a stroke 2. Post-seizure manifestations will last longer 3. Complex partial seizures are the most common type 4. Commonly caused by arteriosclerosis of the cerebrovascular system 5. Anti-seizure medication is not as effective in controlling the seizures

Answer: 1, 2, 3, 4 Explanation: 1. In an older patient, seizures are commonly caused by a stroke. 2. In an older patient, post-seizure manifestations will last longer. 3. In an older patient, complex partial seizures are the most common type. 4. In an older patient, seizures are commonly caused by arteriosclerosis of the cerebrovascular system.

32) A patient is prescribed a medication that affects the beta1- and beta2-receptors in the body. Which effect of this medication should the nurse expect to assess? Select all that apply. 1. Normal heart rate 2. Improved respiration 3. Lower blood pressure 4. Reduced muscle cramps 5. Increased blood glucose level

Answer: 1, 2, 3, 5 Explanation: 1. Beta1-receptors are found in the heart, where they regulate the rate and force of contraction. 2. Beta2-receptors are found in receptor cells of the lungs and help regulate bronchial diameter. 3. Beta2-receptors are found in receptor cells of the arteries and help regulate arterial diameter. 5. Beta2- receptors are found in receptor cells of the liver and help regulate glycogenesis.

37) The nurse is preparing a teaching tool to prevent injuries. What should the nurse include to prevent neurologic injuries due to trauma? Select all that apply. 1. Wear seat belts. 2. Practice vehicular safety. 3. Wear helmets when bicycling. 4. Have an annual eye examination. 5. Wear helmets when riding a motorcycle.

Answer: 1, 2, 3, 5 Explanation: 1. Neurologic injuries due to trauma can be prevented with correct use of safety equipment such as using seat belts. 2. Neurologic injuries due to trauma can be prevented with correct use of safety equipment such as using vehicular safety. 3. Neurologic injuries due to trauma can be prevented with correct use of safety equipment such as wearing helmets when bicycling. 5. Neurologic injuries due to trauma can be prevented with correct use of safety equipment such as wearing helmets when riding a motorcycle.

38) A patient asks what can be done to prevent the development of a neurologic disorder like other family members have developed over the years. What should the nurse recommend to the patient? Select all that apply. 1. Obtain sufficient sleep. 2. Consume a healthy diet. 3. Consider genetic testing. 4. Engage in regular physical activity. 5. Have routine neurologic examinations.

Answer: 1, 2, 4 Explanation: 1. General health promotion actions to positively impact neurologic function include obtaining sufficient sleep. 2. General health promotion actions to positively impact neurologic function include consuming a healthy diet. 4. General health promotion actions to positively impact neurologic function include engaging in regular physical activity.

33) 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? Select all that apply. 1. Damp skin 2. Cold extremities 3. Heart rate 68 bpm 4. Deep, rapid respirations 5. Elevated blood pressure

Answer: 1, 2, 4, 5 Explanation: 1. Stimulation of the sympathetic division exerts effects on target organs or tissues including diaphoresis, leading to damp skin. 2. Stimulation of the sympathetic division exerts effects on target organs or tissues including vasoconstriction of skin blood vessels, leading to cold skin. 4. Stimulation of the sympathetic division exerts effects on target organs or tissues including dilation of the bronchioles, leading to deep, rapid respirations. 5. Stimulation of the sympathetic division exerts effects on target organs or tissues including vasoconstriction of arteries, leading to an elevated blood pressure.

12) The nurse is planning to assess an adult patient with a neurological problem for abnormal posturing. For what posture should the nurse specifically assess? Select all that apply. 1. Decorticate 2. Circumduction 3.Decerebrate 4. Festinating 5. Nystagmus

Answer: 1, 3 1. In decorticate posturing, the upper arms are close to the sides; the elbows, wrists, and fingers are flexed; the legs are extended with internal rotation; and the feet are plantar flexed. 3. In decerebrate posturing, the neck is extended; the jaw is clenched; the arms are pronated, extended, and close to the sides; the legs are extended straight out; and the feet are plantar flexed.

34) 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 finding caused the nurse to have this concern? Select all that apply. 1. The patient smokes 1 ppd of cigarettes. 2. The patient and spouse walk the family dog after dinner. 3. The patient works in a chemical plant that manufactures plastic. 4. The patient plays football with college friends every Saturday afternoon. 5. The patient rides a motorcycle in a state where headgear is not mandatory.

Answer: 1, 3, 4, 5 Explanation: 1. Self-care issues related to neurological problems include the use of tobacco. 3. Risk factors for the development of neurological problems include occupational hazards, such as exposure to toxic chemicals or materials. 4. Self-care issues related to neurological problems include wearing a helmet when participating in contact sports. 5. Self-care issues related to neurological problems include wearing a helmet when riding a motorcycle.

24) The nurse suspects a patient may be experiencing dysfunction related to the acoustic nerve (CN VIII). Which action should the nurse take to minimize the patient's risk for injury? Select all that apply. 1. Identifying the patient's fall risk category 2. Assessing the patient's gag reflex prior to offering food or liquids 3. Assisting the patient with bedside sitting or toileting 4. Assessing the patient's vision using a Snellen chart 5. Placing a red "falls risk" bracelet on the patient's arm

Answer: 1, 3, 5 Explanation: 1. Dysfunction of the acoustic nerve can affect equilibrium and result in vertigo or disturbed balance, putting the patient at risk for falls. 3. Dysfunction of the acoustic nerve can affect equilibrium and increase the risk for falls. Assisting with bedside toileting or sitting would be indicated. 5. Dysfunction of the acoustic nerve can affect equilibrium and increase the patient's risk for falling. A falls risk bracelet would be indicated.

15) A patient is in the hospital with suspected intracerebral hemorrhage. Which neurologic test is most likely to be prescribed for this patient? 1. X-rays of the spine 2. Computed tomography (CT) 3. Evoked potentials 4. Electroencephalogram (EEG)

Answer: 2 2. A computed tomography (CT) scan can visualize intracerebral hemorrhages because the computer-assisted x-rays view several levels of cross-sections of the head.

6) The nurse asks a patient to stand with the feet together and eyes closed. What must the nurse observe for the Romberg test to be considered normal? 1. Swaying from side to side 2. Minimal swaying for up to 20 seconds 3. Sufficient balance to hold completely still without swaying 4. Swaying to one side and loss of balance

Answer: 2 2. A normal result of the Romberg test would be the patient displaying minimal swaying for up to 20 seconds. A positive Romberg test, in which the patient sways and may lose balance, is a sign of cerebellar dysfunction as in cerebellar ataxia.

19) 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? 1. Loss of consciousness 2. Seizures 3. Decerebrate posturing 4. Headache

Answer: 2 2. Abnormal cell firing in the brain causes the recurring seizures characteristic of epilepsy.

1) The nurse is preparing to assess a patient's cognitive function. What should the nurse include in this assessment? 1. Ability to smell items placed under the nose while eyes are closed 2. Orientation to time, place, and person, and ability to recall recent and past events 3. Ability to walk with a smooth, steady gait 4. Level of consciousness

Answer: 2 2. Cognitive function includes orientation to time, place, and person and the ability to recall recent and past events.

30) A patient with a fine tremor in the right hand and arm asks what a primary essential tremor means. What is the best response by the nurse? 1. "Essential tremor occurs 5 to 10 years before the onset of Parkinson disease." 2. "When essential tremor is a primary disorder, it is usually inherited." 3. "Essential tremor is very rare. It affects only about 100,000 people." 4. "People with essential tremor often go on to develop cardiovascular disease."

Answer: 2 2. Essential tremor, as a primary disorder, is usually inherited.

22) 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? 1. "Do you get dizzy when moving from a sitting to standing position?" 2. "Do you have difficulty adjusting to changes in temperature?" 3. "Do you have difficulty falling asleep in the evening?" 4. "Have you had any weight loss?"

Answer: 2 2. Temperature regulation is located in the hypothalamus, which is part of the CNS.

11) 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? 1. Doll's-eyes reflex 2. Brudzinski sign 3. Babinski reflex 4. Kernig sign

Answer: 2 2. The Brudzinski sign is elicited by placing the patient in a supine position and flexing the neck toward the chest. A positive result would be noted if the patient has pain or flexes the hip or knees and indicates meningeal irritation.

26) A patient in the emergency department (ED) has a Glasgow Coma Scale (GCS) score of 8. Which is the most appropriate action by the nurse? 1. Treat the patient's pain. 2. Assess the patient's airway, breathing, and circulation. 3. Obtain a complete history from the patient. 4. Triage the patient with the other ED patients.

Answer: 2 2. The GCS (Glasgow Coma Scale) is a standardized system for assessing consciousness. A score of 15 indicates full alertness; a score of 8 or less is usually indicative of coma; the lowest possible score is 3. A comatose patient receives high priority, and the nurse will utilize the ABCs of care in this case. Additionally, assessment is the first nursing process.

27) The meal tray for a patient with damage to the glossopharyngeal nerve (CN IX) has been delivered. What action should the nurse take first? 1. Tell the patient what food is on the tray. 2. Assess the patient's ability to swallow. 3. Speak loudly and make eye contact with the patient. 4. Assist the patient in identifying where items are on the tray.

Answer: 2 2. The gag reflex and swallowing are controlled by CN IX.

35) A patient is being evaluated for disease of the lower motor neurons. Which assessment finding should the nurse identify as consistent with this health problem? Select all that apply. 1. Spasticity 2. Flaccidity 3. Steppage gait 4. Fasciculations 5. Muscle atrophy

Answer: 2, 3, 4, 5 Explanation: 2. Muscle tone is decreased (flaccidity) in disease or trauma of the lower motor neurons. 3. Steppage gait is noted with disease of the lower motor neurons. 4. Fasciculations occur in disease of or trauma to the lower motor neurons. 5. Atrophy of the muscles is seen with disease of the lower motor neurons.

16) 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? 1. Magnetic resonance imaging (MRI) and computed tomography (CT) 2. Computed tomography (CT) and positron emission tomography (PET) 3. X-rays of the skull and spine and computed tomography (CT) 4. Computed tomography (CT)

Answer: 3 3. It is always important to "clear" the cervical spine by taking x-rays with visualization of all seven cervical vertebrae. A skull x-ray combined with a CT scan to assess for the presence of blood or clots is also important in this case, because ejection from a vehicle usually causes head trauma.

8) 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? 1. The CSF is yellow, without sediment. 2. The CSF is tinged with blood but has no sediment. 3. The CSF is clear and colorless. 4. The CSF is pink, without sediment.

Answer: 3 3. Normal CSF is clear and colorless.

31) The nurse asks a patient who experienced a cerebral vascular accident (CVA) to complete the heel-to-shin test. What is the nurse testing for with this technique? 1. Ataxia 2. Graphesthesia 3. Coordination 4. Spasticity

Answer: 3 3. The heel-to-shin test requires the patient to run each heel down each shin, while in a supine position. This technique tests the patient's coordination.

9) The nurse is assessing a patient's muscle strength and movement. What should the nurse do when completing this assessment? 1. Grade the posterior tibial pulses. 2. Grade flaccidity. 3. Observe whether strength and movement are bilaterally equal and strong. 4. Ask the patient to walk normally in a heel-to-toe sequence.

Answer: 3 3. The nurse should compare one side to the other and note any difference in strength or movement.

4) The nurse wants to determine if a patient is experiencing tremors. When performing this assessment, for what should the nurse observe? 1. Shaking 2. Jerky movements 3. Rhythmic movements 4. Fasciculations

Answer: 3 3. Tremors are rhythmic movements seen with activity or at rest. The type of tremors observed is linked to specific disease processes.

13) A patient is suspected of having a neuromuscular disease. What neurological test helps to diagnose this type of health problem? 1. Single-photon emission computed tomography (SPECT) 2. Positron emission tomography (PET) 3. Magnetic resonance imaging (MRI) 4. Electromyogram (EMG)

Answer: 4 4. An EMG measures the electrical activity of skeletal muscles at rest and during contraction and is useful in diagnosing neuromuscular disease.

5) A patient is exhibiting a lack of coordination, clumsy movements, and an unbalanced gait. What term should the nurse use when documenting these observations? 1. Flaccidity 2. Paralysis 3. Hemiparesis 4. Ataxia

Answer: 4 4. Ataxia is characterized by a lack of coordination, clumsy movements, and an unbalanced gait.

21) 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? 1. Central 2. Peripheral 3. Sympathetic 4. Parasympathetic

Answer: 4 4. The parasympathetic nervous system is responsible for returning the body's functions to normal after they have been stimulated by the sympathetic system.

3) The nurse is preparing to assess a patient's neurologic system. What should the nurse do to assess sensory function? 1. Write a number on the patient's hand and have him or her identify the number. 2. Have the patient distinguish which parts of the body are being touched. 3. Ask the patient to identify two areas of simultaneous pinpricks on the hand. 4.Touch both sides of various parts of the body with a sharp and a dull object.

Answer: 4 Explanation: Sensory function is best evaluated by touching both sides of various parts of the body with a sharp and a dull object.

17) The nurse suspects that an older patient is experiencing age-related changes of a decreased number of brain cells, decreased cerebral blood flow, and decreased metabolism. How would these changes affect the plan of care for the patient at home? Select all that apply. 1. Will be distracted after a few minutes on the task 2. Will not be open to learning to perform a dressing change 3. Will be less reliable at completing self-care activities 4. Will have delayed responses if too many stimuli occur 5. Will have an increased risk for falls

Answer: 4, 5 4. The older adult may need additional time to process and respond to verbal stimuli. 5. Age-related changes can cause slower reflexes, which increase the older adult's risk for falls.