Chapter 54 (test 2) Flashcards
Which divisions are the two divisions of the nervous system?
a. Somatic and the autonomic
b. Cerebellum and the brainstem
c. Medulla oblongata and the diencephalon
d. Central and the peripheral
ANS: D
Which cranial nerve supplies most of the organs in the thoracic and abdominal cavities and carries motor fibers to glands that produce digestive juices and other secretions?
a. Somatic motor nerve
b. Visceral sensory nerve
c. Abducens nerve
d. Vagus nerve
ANS: D
The newly admitted patient to the emergency room 30 minutes ago after a fall off a ladder has gradually decreased in consciousness and has slowly reacting pupils, a widening pulse pressure, and verbal responses that are slow and unintelligible. Which position is most appropriate for the patient?
a. Neck placed in a neutral position.
b. Head raised slightly with hips flexed.
c. Supine in gravity neutral position.
d. Turn on right side with head elevated.
ANS: A
Which question is likely to elicit the most valid response from the patient who is being interviewed about a neurologic problem?
a. “Do you have any sensations of pins and needles in your feet?”
b. “Does the pain radiate from your back into your legs?”
c. “Can you describe the sensations you are having?”
d. “Do you ever have any nausea or dizziness?”
ANS: C
Which sign is the cardinal sign of increased intracranial pressure in a patient who has sustained a brain injury?
a. Pupil changes
b. Ipsilateral paralysis
c. Vomiting
d. Decrease in the level of consciousness
ANS: D
The nurse is aware that when assessing a patient by the FOUR score coma scale, the patient is assessed in four categories: eye response, brainstem reflexes, motor response, and respiration. In which manner are these results reported?
a. As a sum of the scores of the four categories
b. As part of the Glasgow Coma Scale
c. As individual scores in each category
d. As progressive scores during a 24-hour period
ANS: C
As the result of a stroke, a patient has difficulty discerning the position of his body without looking at it. In the nurse’s documentation, which term would best describe the patient’s inability to assess spatial position of his body?
a. Agnosia
b. Loss of proprioception
c. Apraxia
d. Sensation
ANS: B
A patient is to have a myelogram to confirm the presence of a herniated intervertebral disk. Which nursing action will be planned with respect to this diagnostic test?
a. Obtain an allergy history before the test.
b. Ambulate the patient when returned to the room after the test.
c. Use heated blanket to keep patient warm after procedure.
d. Keep NPO for 6 to 8 hours after the test.
ANS: A
A patient has recently experienced a stroke with left-sided weakness and has problems with choking, especially when drinking thin liquids. Which nursing interventions would be most helpful in assisting this patient to swallow safely?
a. Use a straw.
b. Tuck chin when swallowing.
c. Take a sip of liquid with each bite.
d. Turn head to the left.
ANS: B
What are surgical navigational systems?
a. Computerized devices that guide the surgeon
b. A set of detailed anatomic maps pinpointing specific areas of the brain
c. A written set of progressive processes for the resection of small brain tumors
d. The use of radioactive materials to pinpoint small tumors of the brain
ANS: A
A family member of a patient who has just experienced a tonic-clonic seizure is concerned about the patient’s deep sleep. What is this behavior called?
a. Convalescent period
b. Neural recovery period
c. Sombulant period
d. Postictal period
ANS: D
In which way will a nurse record the behavior when a patient with Alzheimer’s disease attempts to eat using a napkin rather than a fork?
a. Apraxia
b. Agnosia
c. Aphasia
d. Dysphagia
ANS: B
Which symptom is specific to migraine headaches?
a. Tachycardia
b. They become worse in the evening
c. They involve the entire head
d. They are preceded by an aura
ANS: D
The nurse assures an anxious family member of a 92-year-old patient who is demonstrating signs of dementia that many causes of dementia are reversible and preventable. Which disorder is one example?
a. Hypotension
b. Alzheimer’s disease
c. Diabetes
d. Parkinson disease
ANS: A
Which aspect is the nurse assessing when asking the patient, “Who is the president of the United States?” during a level of consciousness data collection?
a. Orientation
b. Memory
c. Calculation
d. Knowledge
ANS: D
Which Glasgow Coma Scale rating would a patient receive who opens the eyes spontaneously, but has incomprehensible speech and obeys commands for movement?
a. 8
b. 10
c. 11
d. 12
ANS: D
Which factor is the nurse aware of when assessing a person with a craniocerebral injury?
a. Most injuries of this type are irreversible.
b. Open injuries are always more serious than closed injuries.
c. Signs and symptoms may not occur until several days after the trauma.
d. Trauma to the frontal lobe is more significant than to any other area.
ANS: C
The nurse is caring for a patient who had a spinal cord injury at C5 3 years ago. The nurse expects the plan of care will focus on the knowledge that the patient will be able to do which activity independently?
a. feed self with setup and adaptive equipment.
b. transfer self to wheelchair.
c. stand erect with full leg braces.
d. sit with good balance.
ANS: A
A frantic family member is distressed about the flaccid paralysis of a relative following a spinal cord injury several hours ago. Which fact does the nurse know about this condition?
a. It is an ominous indicator of permanent paralysis.
b. It is possibly a temporary condition and will clear.
c. It degenerates into a spastic paralysis.
d. It will progress up the cord to cause seizures.
ANS: B
A patient with a spinal cord injury at T1 complains of stuffiness of the nose and a headache. The nurse notes a flushing of the neck and “goose flesh.” Which action will be the initial nursing intervention based on these signs?
a. Place patient in flat position and check temperature.
b. Administer oxygen and check oxygen saturation.
c. Place on side and check for leg swelling.
d. Sit upright and check blood pressure.
ANS: D
The nurse is aware that the characteristic gait of the person with Parkinson disease is a propulsive gait, which causes the patient to walk in which manner?
a. stagger and need support of a walker.
b. shuffle with arms flexed.
c. fall over to one wide when walking.
d. take small steps balanced on the toes.
ANS: B
A patient who has experienced a stroke has expressive aphasia. Which abnormal manner of communication does the patient display?
a. Has difficulty comprehending spoken and written communication.
b. Cannot make any vocal sounds.
c. Has total loss and understanding of language.
d. Can understand the spoken word, but cannot speak.
ANS: D
The nurse is aware that the drug t-PA a tissue plasminogen activator, must be given within how many hours of the onset of symptoms to have maximum benefit?
a. 3 hours
b. 4 hours
c. 6 hours
d. 8 hours
ANS: A
An 83-year-old patient has had a stroke. The patient is right handed and has a history of hypertension and “little” strokes. The patient presents with right hemiplegia. To afford the patient the best visual field, the nurse will approach the patient in which manner?
a. from the right side.
b. from the left side.
c. from the center.
d. from either side.
ANS: B
The newly admitted patient to the emergency room after a motorcycle accident has serosanguineous drainage coming from the nose. Which is the appropriate nursing response to this finding?
a. Cleanse nose with a soft cotton-tipped swab.
b. Gently suction the nasal cavity.
c. Gently wipe nose with absorbent gauze.
d. Ask patient to blow his nose.
ANS: C
In which way will the nurse instruct a patient with Parkinson disease to improve activity level?
a. To use a soft mattress to relax the spine.
b. To walk with a shuffling gait to avoid tripping.
c. To walk with hands folded behind back to help balance.
d. To sit in hard chair with arms for posture control.
ANS: C
Which issue is the basic problem that prompts most of the early signs of Alzheimer’s disease (AD)?
a. Changes in mood
b. Misplacing things
c. Memory loss that disrupts daily life
d. Problems with words in speaking
ANS: C
A patient is in which stage of Alzheimer’s disease when demonstrating difficulty swallowing?
a. Pre-Alzheimer’s
b. Early
c. Middle
d. Late
ANS: D
Which benefit do the drugs neostigmine and pyridostigmine have for the person with myasthenia gravis?
a. Improves speech.
b. Improves visual disturbances.
c. Reduces pain.
d. Promotes nerve impulse transmission.
ANS: D
Which action will the nurse take when caring for a child recently diagnosed with bacterial meningitis?
a. Arrange for humidified oxygen per mask.
b. Place the child in respiratory isolation.
c. Inquire about drug allergy.
d. Hold NPO until orders arrive.
ANS: B
For which reason is a “drug holiday” used in the treatment of Parkinson disease?
a. Change all drugs.
b. Allow the natural dopamine levels to rise.
c. Restart drugs at a lower dosage with favorable results.
d. Reduce the extrapyramidal symptoms.
ANS: C
Which sign is the first sign of Bell’s palsy?
a. Inability to wrinkle forehead and pucker lips on affected side
b. Sudden pain in nostril on affected side
c. Excessive salivation on the affected side
d. Excessive mucus running from nostril on affected side
ANS: A
Following a myelogram the nurse will include in the postprocedure care observing for which possible complication?
a. elevation of blood pressure.
b. urine retention.
c. Loss of sensation in lower extremities.
d. slurred speech.
ANS: C
For which reason is the patient with suspected Guillain-Barre Syndrome (GBS) hospitalized immediately?
a. The infection needs to be treated with IV antibiotics to prevent paralysis.
b. The brain may swell quickly causing seizures.
c. The disease can rapidly progress into respiratory failure.
d. IV hydration is needed to prevent possible fatal hypotension.
ANS: C
The nurse explains that the two divisions of the autonomic nervous system work to maintain homeostasis. Which action is the first autonomic event following a stressful or frightening event?
a. Parasympathetic nervous system dominates
b. Blood pressure, heart rate, and adrenaline output decrease
c. Sympathetic nervous system dominates
d. Heart rate and blood pressure rise, secretion of adrenaline
ANS: D
