Ch. 24 Neurological

Question 1

What are the two parts of the nervous system?

a. Motor and sensory
b. Central and peripheral
c. Peripheral and autonomic
d. Hypothalamus and cerebral

Answer 1

ANS: B

The nervous system can be divided into two parts—central and peripheral. The central nervous system includes the brain and spinal
cord. The peripheral nervous system includes the 12 pairs of cranial nerves (CNs), the 31 pairs of spinal nerves, and all of their
branches. Motor and sensory refer to the two types of nerve tract pathways in the CNS. Peripheral and autonomic both are part of
the peripheral part of the nervous system. The peripheral nervous system has two parts, the somatic and autonomic. The
hypothalamus and cerebral are parts of the brain.

Question 2

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband’s personality
and ability to understand. He also cries very easily and becomes angry. What part of the cerebral lobe is responsible for these
behaviors?
a. Frontal
b. Parietal
c. Occipital
d. Temporal

Answer 2

ANS: A

The frontal lobe has areas responsible for personality, behavior, emotions, and intellectual function. The parietal lobe has areas
responsible for sensation; the occipital lobe is responsible for visual reception; and the temporal lobe is responsible for hearing,
taste, and smell.

Question 3

Which statement concerning the areas of the brain is true?

a. The cerebellum is the center for speech and emotions.
b. The hypothalamus controls body temperature and regulates sleep.
c. The basal ganglia are responsible for controlling voluntary movements.
d. Motor pathways of the spinal cord and brainstem synapse in the thalamus.

Answer 3

ANS: B

The hypothalamus is a vital area with many important functions: body temperature controller, sleep center, anterior and posterior
pituitary gland regulator, and coordinator of autonomic nervous system activity and emotional status. The cerebellum controls
motor coordination, equilibrium, and balance. The basal ganglia control autonomic movements of the body. The motor pathways of
the spinal cord synapse in various areas of the spinal cord, not in the thalamus

Question 4

The area of the nervous system that responsible for mediating reflexes?

a. Medulla
b. Cerebellum
c. Spinal cord
d. Cerebral cortex

Answer 4

ANS: C

The spinal cord is the main highway for ascending and descending fiber tracts that connect the brain to the spinal nerves; it is
responsible for mediating reflexes. The medulla is the continuation of the spinal cord in the brain that contains all ascending and
descending fiber tracts. Pyramidal decussation (crossing of the motor fibers) occurs here. The cerebellum is a coiled structure
located under the occipital lobe that is concerned with motor coordination of voluntary movements, equilibrium, and muscle tone.
The cerebral cortex is the outer layer of nerve cell bodies and is the center for a human’s highest functions, governing thought,
memory, reasoning, sensation, and voluntary movement.

Question 5

While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret
this sensation, which of these areas must be intact?
a. Corticospinal tract, medulla, and basal ganglia
b. Pyramidal tract, hypothalamus, and sensory cortex
c. Lateral spinothalamic tract, thalamus, and sensory cortex
d. Anterior spinothalamic tract, basal ganglia, and sensory cortex

Answer 5

ANS: C

The spinothalamic tract contains sensory fibers that transmit the sensations of pain, temperature, and crude or light touch. Fibers
carrying pain and temperature sensations ascend the lateral spinothalamic tract, whereas the sensations of crude touch form the
anterior spinothalamic tract. At the thalamus, the fibers synapse with another sensory neuron, which carries the message to the
sensory cortex for full interpretation. The other options are not correct.

Question 6

A patient with a lack of oxygen to his heart will have pain in his chest and possibly in the shoulder, arms, or jaw. The nurse knows
that the best explanation why this occurs is which one of these statements?
a. A problem exists with the sensory cortex and its ability to discriminate the
location.
b. The lack of oxygen in his heart has resulted in decreased amount of oxygen to the
areas experiencing the pain.
c. The sensory cortex does not have the ability to localize pain in the heart;
consequently, the pain is felt elsewhere.
d. A lesion has developed in the dorsal root, which is preventing the sensation from
being transmitted normally.

Answer 6

ANS: C

The sensory cortex is arranged in a specific pattern, forming a corresponding map of the body. Pain in the right hand is perceived at
a specific spot on the map. Some organs, such as the heart, liver, and spleen, are absent from the brain map. Pain originating in
these organs is referred because no felt image exists in which to have pain. Pain is felt by proxy, that is, by another body part that
does have a felt image. The other responses are not correct explanations.

Question 7

What controls humans’ ability to perform very skilled movements such as writing?

a. Basal ganglia
b. Corticospinal tract
c. Spinothalamic tract
d. Extrapyramidal tract

Answer 7

ANS: B

Corticospinal fibers mediate voluntary movement, particularly very skilled, discrete, and purposeful movements, such as writing.
The corticospinal tract, also known as the pyramidal tract, is a newer, “higher” motor system that humans have that permits very
skilled and purposeful movements. The other responses are not r/t skilled movements. The basal ganglia are large bands of gray
matter buried deep within the two cerebral hemispheres that from the subcortical-associated motor system and help to initiate and
coordinate movement and control automatic associated movements of the body (e.g. arm swing alternating with the legs during
walking). The spinothalamic tract is one of the major sensory pathways of the CNS and has two parts. The lateral spinothalamic
tract carries pain and temperature sensations and the anterior spinothalamic tract carries crude touch. The extrapyramidal tracts
include all the motor nerve fibers originating in the motor cortex, basal ganglia, brainstem, and spinal cord that are outside the
pyramidal tract and maintains muscle tone and control body movements, especially gross automatic movements such as walking.

Question 8

A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area
of the brain most concerns the nurse?
a. Thalamus
b. Brainstem
c. Cerebellum
d. Extrapyramidal tract

Answer 8

ANS: C

The cerebellar system coordinates movement, maintains equilibrium, and helps maintain posture. So the nurse would be most
concerned about this area of the brain. The thalamus is the primary relay station where sensory pathways of the spinal cord,
cerebellum, and brainstem form synapses on their way to the cerebral cortex. The brainstem consists of the midbrain, pons, and
medulla and has various functions, especially concerning autonomic centers. The extrapyramidal tract maintains muscle tone for
gross automatic movements, such as walking. The thalamus is the primary relay station where sensory pathways of the spinal cord,
cerebellum, and brainstem form synapses on their way to the cerebral cortex. The brainstem consists of the midbrain, pons, and
medulla and has various functions, especially concerning autonomic centers. The extrapyramidal tract maintains muscle tone for
gross automatic movements, such as walking. With this patient’s unsteady gait and balance problems, the nurse would be most
concerned with the cerebellum.

Question 9

Which of these statements about the peripheral nervous system is correct?
a. The CNs enter the brain through the spinal cord.
b. Efferent fibers carry sensory input to the central nervous system through the
spinal cord.
c. The peripheral nerves are inside the central nervous system and carry impulses
through their motor fibers.
d. The peripheral nerves carry input to the central nervous system by afferent fibers
and away from the central nervous system by efferent fibers.

Answer 9

ANS: D

A nerve is a bundle of fibers outside of the central nervous system. The peripheral nerves carry input to the central nervous system
by their sensory afferent fibers and deliver output from the central nervous system by their efferent fibers. The other responses are
not r/t the peripheral nervous system.

Question 10

A patient has a severed spinal nerve as a result of trauma. Which statement is true in this situation?
a. Because there are 31 pairs of spinal nerves, no effect results if only one nerve is
severed.
b. The dermatome served by this nerve will no longer experience any sensation.
c. The adjacent spinal nerves will continue to carry sensations for the dermatome
served by the severed nerve.
d. A severed spinal nerve will only affect motor function of the patient because
spinal nerves have no sensory component.

Answer 10

ANS: C

A dermatome is a circumscribed skin area that is primarily supplied from one spinal cord segment through a particular spinal nerve.
The dermatomes overlap, which is a form of biologic insurance; that is, if one nerve is severed, then most of the sensations can be
transmitted by the spinal nerve above and the spinal nerve below the severed nerve.

Question 11

A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the
assessment what would the nurse expect to find when testing the patient’s deep tendon reflexes?
a. Reflexes will be normal.
b. Reflexes cannot be elicited.
c. All reflexes will be diminished but present.
d. Some reflexes will be present, depending on the area of injury.

Answer 11

ANS: A

A reflex is a defense mechanism of the nervous system. It operates below the level of conscious control and permits a quick
reaction to potentially painful or damaging situations.

Question 12

During an assessment of an 80-year-old patient, the nurse notices the following: an inability to identify vibrations at her ankle and
to identify the position of her big toe, a slower and more deliberate gait, and a slightly impaired tactile sensation. All other
neurologic findings are normal. How should the nurse interpret these findings?
a. CNS dysfunction
b. Lesion in the cerebral cortex
c. Normal changes attributable to aging
d. Demyelination of nerves attributable to a lesion

Answer 12

ANS: C

Some aging adults show a slower response to requests, especially for those calling for coordination of movements. The findings
listed are normal in the absence of other significant abnormal findings. The other responses are incorrect.

Question 13

A 70-year-old woman tells the nurse that every time she gets up in the morning or after she’s been sitting for a while, she gets
“really dizzy” and feels like she is going to fall over. What is the best response by the nurse?
a. “Have you been extremely tired lately?”
b. “You probably just need to drink more liquids.”
c. “I’ll refer you for a complete neurologic examination.”
d. “You need to get up slowly when you’ve been lying down or sitting.”

Answer 13

ANS: D

This patient’s symptoms are unlikely r/t being tired or dehydration and would not require a complete neurological examination at
this time. Instead, they are likely due to normal aging. Aging is accompanied by a progressive decrease in cerebral blood flow. In
some people, this decrease causes dizziness and a loss of balance with a position change. These individuals need to be taught to get
up slowly. The other responses are incorrect.

Question 14

During the taking of the health history, a patient tells the nurse that “it feels like the room is spinning around me.” How should the
nurse document this finding?
a. Vertigo
b. Syncope
c. Dizziness
d. Seizure activity

Answer 14

ANS: A

True vertigo is rotational spinning caused by a neurologic dysfunction or a problem in the vestibular apparatus or the vestibular
nuclei in the brainstem. Syncope is a sudden loss of strength or a temporary loss of consciousness. Dizziness is a light-headed,
swimming sensation. Seizure activity is characterized by altered or loss of consciousness, involuntary muscle movements, and
sensory disturbances.

Question 15

When taking the health history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of
these would be the best question for obtaining this information?
a. “Does your muscle tone seem tense or limp?”
b. “After the seizure, do you spend a lot of time sleeping?”
c. “Do you have any warning sign before your seizure starts?”
d. “Do you experience any color change or incontinence during the seizure?”

Answer 15

ANS: C

Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or motor. The other questions do not solicit
information about an aura.

Question 16

In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks alcohol daily and that he has noticed a tremor
in his hands that affects his ability to hold things. With this information, what response should the nurse make?
a. “Does the tremor change when you drink alcohol?”
b. “Does your family know you are drinking every day?”
c. “We’ll do some tests to see what is causing the tremor.”
d. “You really shouldn’t drink so much alcohol; it may be causing your tremor.”

Answer 16

ANS: A

Although not a recommended treatment, senile tremor is relieved by alcohol. The nurse should assess how alcohol affects the
tremor and whether the person is abusing alcohol in an effort to relieve the tremor. Asking whether the family knows he drinks
daily does not address the issue of the tremor and it is possible cause. Before ordering tests, a thorough assessment should be
performed. Telling the patient he shouldn’t drink so much and that drinking may be the cause of his tremor is inappropriate and will
likely make the patient defensive.

Question 17

A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should
perform which type of neurologic examination?
a. Glasgow Coma Scale
b. Neurologic recheck examination
c. Complete neurologic examination
d. Screening neurologic examination

Answer 17

ANS: C

The nurse should perform a complete neurologic examination on an individual who has neurologic concerns (e.g., headache,
weakness, loss of coordination) or who is showing signs of neurologic dysfunction. The Glasgow Coma Scale is used to define a
person’s level of consciousness. The neurologic recheck examination is appropriate for those who are demonstrating neurologic
deficits. The screening neurologic examination is performed on seemingly well individuals who have no significant subjective
findings from the health history.

Question 18

During an assessment of the cranial nerves (CNs), the nurse finds the following: asymmetry when the patient smiles or frowns,
uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed
cheek. These findings indicate dysfunction of which cranial nerve(s)?
a. Motor component of CN IV
b. Motor component of CN VII
c. Motor and sensory components of CN XI
d. Motor component of CN X and sensory component of CN VII

Answer 18

ANS: B

The nurse’s findings all reflect motor dysfunction, none are sensory. The specific cranial nerve affected is the facial nerve (CN
VII). Cranial nerve IV, the trochlear nerve, innervates a muscle in the eye muscle and is responsible for eye movement, not the
symptoms this patient is experiencing. The nurse’s findings all reflect motor dysfunction, none are sensory, therefore options c and
d can be eliminated because they each contain a sensory component.

Question 19

The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is
intact?
a. Patient demonstrates the ability to hear normal conversation.
b. When patient sticks out tongue it is midline and without tremors or deviation.
c. Patient follows an object with his or her eyes without nystagmus or strabismus.
d. Patient moves the head and shoulders against resistance with equal strength.

Answer 19

ANS: D

The following normal findings are expected when testing the spinal accessory nerve (CN XI): The patient’s sternomastoid and
trapezius muscles are equal in size; the person can forcibly rotate the head both ways against resistance applied to the side of the
chin with equal strength; and the patient can shrug the shoulders against resistance with equal strength on both sides. Checking the
patient’s ability to hear normal conversation checks the function of CN VIII. Having the patient stick out the tongue checks the
function of CN XII. Testing the eyes for nystagmus or strabismus is performed to check CNs III, IV, and VI.

Question 20

During the neurologic assessment of a “healthy” 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse
then moves each extremity through full range of motion. Which of these results would the nurse expect to find?
a. Firm, rigid resistance to movement
b. Mild, even resistance to movement
c. Slight pain with some directions of movement
d. Hypotonic muscles as a result of total relaxation.

Answer 20

ANS: B

Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows a mild resistance to passive stretching.
Normally the nurse will notice a mild, even resistance to movement. The other responses are not correct.

Question 21

When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway
and moves his feet farther apart. How should the nurse document this finding?
a. Ataxia
b. Lack of coordination
c. Negative Homan sign
d. Positive Romberg sign

Answer 21

ANS: D

This is an abnormal, or positive, Romberg test. Abnormal findings for the Romberg test include swaying, falling, and a widening
base of the feet to avoid falling. A positive Romberg sign is a loss of balance that is increased by the closing of the eyes. Ataxia is
an uncoordinated or unsteady gait. Homan sign is used to test the legs for deep-vein thrombosis. Ataxia is an uncoordinated or
unsteady gait. Homan sign is used to test the legs for deep-vein thrombosis. These findings are an abnormal, or positive, Romberg
test. Abnormal findings for the Romberg test include swaying, falling, and a widening base of the feet to avoid falling.

Question 22

. The nurse is performing an assessment on a 29-year-old woman who visits the clinic reporting “always dropping things and falling
down.” While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her
response is extremely slow and she frequently misses. What should the nurse suspect?
a. Lesion of CN IX
b. Vestibular disease
c. Dysfunction of the cerebellum
d. Inability to understand directions

Answer 22

ANS: C

The symptoms this patient has been experiencing indicate dysfunction of the cerebellum. The cerebellum is concerned with motor
coordination of voluntary movements, equilibrium, and muscle tone. When a person tries to perform rapid, alternating movements,
responses that are slow, clumsy, and sloppy are indicative of cerebellar disease. Vestibular disease causes problems with balance
and vertigo. Lesions of CN IX cause problems swallowing or gagging. Inability to understand directions would be r/t a problem in
Wernicke’s area in the brain and is not associated with dropping things or falling down.

Question 23

During the taking of the health history of a 78-year-old man, his wife states that he occasionally has problems with short-term
memory loss and confusion: “He can’t even remember how to button his shirt.” When assessing his sensory system, which action
by the nurse is most appropriate?
a. The nurse would perform the tests, knowing that mental status does not affect
sensory ability.
b. The nurse would proceed with an explanation of each test, making certain that the
wife understands.
c. Before testing, the nurse would assess the patient’s mental status and ability to
follow directions.
d. The nurse would not test the sensory system as part of the examination because
the results would not be valid.

Answer 23

ANS: C

The nurse should ensure the validity of the sensory system testing by making certain that the patient is alert, cooperative,
comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading and invalid results.

Question 24

The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception, the nurse decides to
complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able
to identify these as one “very sharp prick.” What would be the most accurate explanation for this?
a. The patient has hyperesthesia as a result of the aging process.
b. This response is most likely the result of the summation effect.
c. The nurse was probably not poking hard enough with the pin in the other areas.
d. The patient most likely has analgesia in some areas of arm and hyperalgesia in
others.

Answer 24

ANS: B

At least 2 seconds should be allowed to elapse between each stimulus to avoid summation. With summation, frequent consecutive
stimuli are perceived as one strong stimulus. The other responses are incorrect.

Question 25

The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to
feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally,
but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect?

Answer 25

ANS: C

Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism). Peripheral neuropathy is worse at the feet
and gradually improves as the examiner moves up the leg, as opposed to a specific nerve lesion, which has a clear zone of deficit
for its dermatome. The other responses are incorrect.

Question 26

The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this
finding?
a. Extinction
b. Stereognosis
c. Graphesthesia
d. Tactile discrimination

Answer 26

ANS: B

Stereognosis is the person’s ability to recognize objects by feeling their forms, sizes, and weights. Astereognosis is an inability to
identify objects correctly, and it occurs in sensory cortex lesions. Extinction tests the person’s ability to feel sensations on both
sides of the body at the same point. Graphesthesia is the ability to “read” a number by having it traced on the skin. Tactile
discrimination tests fine touch.

Question 27

The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When
striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit a reflex. How should the nurse proceed?
a. Ask the patient to lock her fingers and pull.
b. Document these reflexes as 0 on a scale of 0 to 4+.
c. Refer the patient to a specialist for further testing.
d. Complete the examination, and then test these reflexes again.

Answer 27

ANS: A

Sometimes the reflex response fails to appear. Documenting the reflexes as absent is inappropriate this soon in the examination.
The nurse should try to further encourage relaxation, varying the person’s position or increasing the strength of the blow.
Reinforcement is another technique to relax the muscles and enhance the response. The person should be asked to perform an
isometric exercise in a muscle group somewhat away from the one being tested. For example, to enhance a patellar reflex, the
person should be asked to lock the fingers together and pull.

Question 28

In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What
might the nurse expect to find when testing his reflexes on the right side?
a. Normal reflexes
b. Lack of reflexes
c. Diminished reflexes
d. Hyperactive reflexes

Answer 28

ANS: D

Hyperreflexia is the exaggerated reflex observed when the monosynaptic reflex arc is released from the influence of higher cortical
levels. This response occurs with upper motor neuron lesions (e.g., a cerebrovascular accident). The other responses are incorrect.

Question 29

When the nurse is testing the triceps reflex, what is the expected response?

a. Flexion of the hand
b. Pronation of the hand
c. Flexion of the forearm
d. Extension of the forearm

Answer 29

ANS: D

The normal response of the triceps reflex is extension of the forearm. The normal response of the biceps reflex causes flexion of the
forearm. The other responses are incorrect.

Question 30

The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the
foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding?
a. Positive Babinski sign
b. Plantar reflex abnormal
c. Plantar reflex present
d. Plantar reflex 2+ on a scale from “0 to 4+”

Answer 30

ANS: C

With a reflex hammer, the nurse should draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot,
similar to an upside-down J. The normal response is plantar flexion of the toes and sometimes of the entire foot. A positive
Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and fanning of all toes. The plantar reflex is
not graded on a 0 to 4+ scale.

Question 31

To test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate?

a. Have the child hop on one foot.
b. Have the child stand on his head.
c. Ask the child to touch his finger to his nose.
d. Ask the child to make “funny” faces at the nurse.

Answer 31

ANS: A

Normally a child can hop on one foot and balance on one foot for approximately 5 seconds by 4 years of age and can balance on
one foot for 8 to 10 seconds at 5 years of age. Children enjoy performing these tests. Failure to hop after 5 years of age indicates
incoordination of gross motor skills. Asking the child to touch his or her finger to the nose checks fine motor coordination; and
asking the child to make “funny” faces tests CN VII. Asking a child to stand on his or her head is not appropriate.

Question 32

During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and
his head is always nodding. No associated rigidity is observed with movement. Which of these statements is most accurate?
a. These findings are normal, resulting from aging.
b. These findings could be r/t hyperthyroidism.
c. These findings are the result of Parkinson disease.
d. This patient should be evaluated for a cerebellar lesion.

Answer 32

ANS: A

Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or

no) , and tongue protrusion. Tremors associated with Parkinson disease include rigidity, slowness, and a weakness of voluntary
movement. The other responses are incorrect.

Question 33

The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse
include in the assessment?
a. CNs, motor function, and sensory function
b. Deep tendon reflexes, vital signs, and coordinated movements
c. Level of consciousness, motor function, pupillary response, and vital signs
d. Mental status, deep tendon reflexes, sensory function, and pupillary response

Answer 33

ANS: C

People who have a neurologic deficit from a systemic disease process, head trauma, or neurosurgery are at increased risk for
developing increased intracranial pressure. These people must be closely monitored for any improvement or deterioration in
neurologic status. The nurse should use an abbreviation of the neurologic examination in the following sequence: level of
consciousness, motor function, pupillary response, and vital signs.

Question 34

During an assessment of a 22-year-old woman who sustained a head injury from an automobile accident 4 hours earlier, the nurse
notices the following changes: pupils were equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm
and reacts to light. What do these findings suggest?
a. Injury to the O.D.
b. Test inaccurately performed
c. Increased intracranial pressure
d. Normal response after a head injury

Answer 34

ANS: C

In a person with a brain injury, a sudden, unilateral, dilated, and nonreactive pupil is ominous. CN III runs parallel to the brainstem.
When increasing intracranial pressure pushes down the brainstem (uncal herniation), it puts pressure on CN III, causing pupil
dilation. The other responses are incorrect.

Question 35

During an assessment of a 62-year-old man, the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat
facial expression, and pill-rolling finger movements. What do these findings suggest?
a. Parkinsonism
b. Cerebral palsy
c. Cerebellar ataxia
d. Muscular dystrophy

Answer 35

ANS: A

The stooped posture, shuffling walk, short steps, flat facial expression, and pill-rolling finger movements are all found in
parkinsonism. Cerebral palsy is dysfunction of a mixed group of paralytic neuromotor disorders of infancy and childhood due to
damage to cerebral cortex from a developmental defect, intrauterine meningitis, encephalitis, birth trauma, anoxia, or kernicterus
and may present as spasticity or athetosis. The characteristics of cerebellar ataxia include a staggering, wide-based gait; difficulty
with turns; and uncoordinated movement with positive Romberg sign. Muscular dystrophy is a chronic, progressive wasting of the
musculature, which produces weakness, contractures, and in severe cases respiratory dysfunction and death. Weak pelvis muscles
and decreased or absent reflexes are signs of muscular dystrophy.

Question 36

During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by
extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion.
Which statement concerning these findings is most accurate? What do these findings indicate?
a. A lesion of the cerebral cortex
b. A completely nonfunctional brainstem
c. Normal findings that will resolve in 24 to 48 hours
d. A very ominous sign and may indicate brainstem injury

Answer 36

ANS: D

These findings are all indicative of decerebrate rigidity, which is a very ominous condition and may indicate a brainstem injury

Question 37

A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his left arm is immobile against
the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and
circumducts with each step. What type of gait disturbance is this individual experiencing?
a. Scissors gait
b. Cerebellar ataxia
c. Parkinsonian gait
d. Spastic hemiparesis

Answer 37

ANS: D

With spastic hemiparesis, the arm is immobile against the body. Flexion of the shoulder, elbow, wrist, and fingers occurs, and
adduction of the shoulder, which does not swing freely, is observed. The leg is stiff and extended and circumducts with each step.
Causes of this type of gait include cerebrovascular accident. With scissors gait the knees cross or are in contact, like holding an
orange between the thighs, and the person uses short steps, and walking requires effort. The characteristics of cerebellar ataxia
include a staggering, wide-based gait; difficulty with turns; and uncoordinated movement with positive Romberg sign.
Parkinsonian gait presents with a stooped posture with trunk pitched forward. Elbows, hips and knees are flexed. Steps are short
and shuffling. The gait disturbance of this patient is spastic hemiparesis. With spastic hemiparesis, the arm is immobile against the
body. Flexion of the shoulder, elbow, wrist, and fingers occurs, and adduction of the shoulder, which does not swing freely, is
observed. The leg is stiff and extended and circumducts with each step. Causes of this type of gait include cerebrovascular accident.

Question 38

In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings
should the nurse expect?
a. Hyperreflexia
b. Fasciculations
c. Loss of muscle tone and flaccidity
d. Atrophy and wasting of the muscles

Answer 38

ANS: A
Hyperreflexia, diminished or absent superficial reflexes, and increased muscle tone or spasticity can be expected with upper motor
neuron lesions. The other options reflect a lesion of lower motor neurons.

Question 39

A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on
physical assessment of this individual?
a. Hyporeflexia
b. Increased muscle tone
c. Positive Babinski sign
d. Presence of pathologic reflexes

Answer 39

ANS: A

With a herniated intervertebral disk or lower motor neuron lesion, loss of tone, flaccidity, atrophy, fasciculations, and hyporeflexia
or areflexia are demonstrated. No Babinski sign or pathologic reflexes would be observed. The other options reflect a lesion of
upper motor neurons.

Question 40

A patient is unable to perform rapid alternating movements such as rapidly patting her knees. How should the nurse document this
finding?
a. Ataxia
b. Astereognosis
c. Loss of kinesthesia
d. Presence of dysdiadochokinesia

Answer 40

ANS: D

Slow clumsy movements and the inability to perform rapid alternating movements occur with cerebellar disease. The condition is
termed dysdiadochokinesia. Ataxia is an uncoordinated or unsteady gait. Astereognosis is the inability to identify an object by
feeling it. Kinesthesia is the person’s ability to perceive passive movement of the extremities or the loss of position sense.

Question 41

The nurse should test the functioning of which structure(s) when determining whether a person is oriented to his or her
surroundings?
a. Cerebellum
b. Cranial nerves
c. Cerebral cortex
d. Medulla oblongata

Answer 41

ANS: C

The cerebral cortex (the outer layer of the cerebrum) is responsible for thought, memory, reasoning, sensation, and voluntary
movement. Thus, determining orientation would assess the functioning of the cerebral cortex. The cerebellum is a coiled structure
located under the occipital lobe that is concerned with motor coordination of voluntary movements, equilibrium, and muscle tone,
but not a person’s thought processes or orientation. The cranial nerves are responsible for relaying sensory and motor information
to and from the brain, but are not involved in thought processes or orientation. The medulla oblongata is located in the brainstem
and it has vital autonomic (involuntary) centers (respiration, heart, gastrointestinal function) and nuclei of cranial nerves VIII
through XII. Pyramidal d

Question 42

During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct?

a. A normal occurrence
b. Indicates disease of the cerebellum or brainstem
c. A sign that the patient is nervous about the examination
d. Indicates a visual problem, and a referral to an ophthalmologist is indicated

Answer 42

ANS: B

End-point nystagmus at an extreme lateral gaze normally occurs; however, the nurse should carefully assess any other
nystagmuses. Severe nystagmus occurs with disease of the vestibular system, cerebellum, or brainstem.

Question 43

. What does testing kinesthesia assess?

a. Fine touch
b. Position sense
c. Motor coordination
d. Perception of vibration

Answer 43

ANS: B

Kinesthesia, or position sense, is the person’s ability to perceive passive movements of the extremities. Fine touch is assessed by
the stereognosis, graphesthesia, extinction, and point location tests. Motor coordination is assessed by the Denver II test and
reflexes. Perception of vibration is assessed by hitting a tuning fork so that it is vibrating and placing it on boney prominences.

Question 44

A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination; he said he
fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurse’s finger, then his own
nose, then the nurse’s finger again (which has been moved to a different location). The patient is clumsy, unable to follow the
instructions, and overshoots the mark, missing the finger. What does the nurse suspect?
a. Cerebral injury
b. Peripheral neuropathy
c. Cerebrovascular accident
d. Acute alcohol intoxication

Answer 44

ANS: D

During the finger-to-finger test, if the person has clumsy movement with overshooting the mark, either a cerebellar disorder or
acute alcohol intoxication should be suspected. The person’s movements should be smooth and accurate. The other options are not
correct.

Question 45

The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws
a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient’s toes fan out,
and the big toe shows dorsiflexion. How should the nurse interpret these findings?
a. Clonus, which is a hyperactive response
b. Achilles reflex, which is an expected response
c. Negative Babinski sign, which is normal for adults
d. Positive Babinski sign, which is abnormal for adults

Answer 45

ANS: D

Dorsiflexion of the big toe and fanning of all toes is a positive Babinski sign, also called up-going toes. This response occurs with
upper motor neuron disease of the corticospinal (or pyramidal) tract and is an abnormal finding for adults.

Question 46

A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused.
He laughs when he is found to be forgetful, saying “I’m just getting old!” After the nurse completes a thorough neurologic
assessment, which findings would be indicative of Alzheimer disease? (Select all that apply.)
a. Getting lost in one’s own neighborhood
b. Occasionally forgetting names or appointments
c. Sometimes having trouble finding the right word
d. Misplacing items, such as putting dish soap in the refrigerator
e. Difficulty performing familiar tasks, such as placing a telephone call
f. Rapid mood swings, from calm to tears, for no apparent reason.

Answer 46

ANS: A, D, E, F

Difficulty performing familiar tasks, misplacing items, rapid mood swings, and getting lost in one’s own neighborhood can be
warning signs of Alzheimer disease. Occasionally forgetting names or appointments, and sometimes having trouble finding the
right word are part of normal aging.

Question 47

During the assessment of deep tendon reflexes, the nurse finds that a patient’s responses are bilaterally normal. What number is
used to indicate normal deep tendon reflexes when the documenting this finding? ____+Correct.

Answer 47

ANS: 2

Responses to assessment of deep tendon reflexes are graded on a 4-point scale. A rating of 2+ indicates normal or average
response. A rating of 0 indicates no response, and a rating of 4+ indicates very brisk, hyperactive response with clonus, which is
indicative of disease.