Lewis: Chapter 55: Assessment: Nervous System

Question 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.

Answer 1

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.

Question 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

Answer 2

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.

Question 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

Answer 3

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.

Question 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.

Answer 4

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.

Question 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.

Answer 5

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.

Question 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.

Answer 6

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.

Question 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.

Answer 7

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.

Question 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

Answer 8

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.

Question 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.

Answer 9

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.

Question 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

Answer 10

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.

Question 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)

Answer 11

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.

Question 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

Answer 12

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.

Question 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

Answer 13

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.

Question 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.

Answer 14

ANS: C
When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate.

Question 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

Answer 15

ANS: B
The protein level is high. The specific gravity, WBCs, and glucose values are normal.

Question 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.

Answer 16

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.

Question 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

Answer 17

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.

Question 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

Answer 18

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.

Question 19

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.

Answer 19

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.

Question 20

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.

Answer 20

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.