Unit S-Neurological/Sensory System Flashcards
The nurse teaches an 80-year-old client with diminished peripheral sensation. Which
statement would the nurse include in this client’s 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 injuries 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 his or her 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 nurse assesses a client’s recent memory. Which statement by the client confirms that
recent 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 recent memory. 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
immediate memory.
A client is admitted to the emergency department with a probable traumatic brain injury.
Which assessment finding would be the priority for the nurse to report to the primary health
care provider?
a. Mild temporal headache
b. Pupils equal and react to light
c. Alert and oriented 3
d. Decreasing level of consciousness
ANS:D
A decreasing level of consciousness is the first sign of increasing intracranial pressure, a
potentially severe and possibly fatal complication of a traumatic brain injury (TBI). A mild
headache would be expected for a client having a TBI. Equal reactive pupils and being alert
and oriented are normal assessment findings.
A nurse asks a client to take deep breaths during an electroencephalography. The client asks,
“Why are you asking me to do this?” How would 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 increase the
likelihood of seizure activity. The client is asked to breathe deeply 20 times for 3 minutes.
The other responses are not accurate.
A nurse assesses a client recovering from a cerebral angiography via the right femoral artery.
Which assessment would 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 (eye) examination
would not be affected by cerebral angiography. The client is not given general anesthesia;
therefore, the client’s gag reflex would not be compromised.
When assessing a client who had a traumatic brain injury, the nurse notes that the client is
drowsy but easily aroused. What level of consciousness will the nurse document to describe
this client’s current level of consciousness?
a. Alert
b. Lethargic
c. Stuporous
d. Comatose
ANS: B
The client is categorized as being lethargic because he or she can be easily aroused even
though drowsy. The nurse would carefully monitor the client to determine any decrease in the
level of consciousness (LOC).
The nurse is assessing a client diagnosed with trigeminal neuralgia affecting cranial nerve V.
What assessment findings will the nurse expect for this client?
a. Expressive aphasia
b. Ptosis (eyelid drooping)
c. Slurred speech
d. Severe facial pain
ANS: D
Cranial nerve (CN) V is the Trigeminal Nerve which has both a motor and sensory function in
the face. When affected by a health problem, the client experiences severely facial pain.
Expressive aphasia results from damage to the Broca speech area in the frontal lobe of the
brain. Ptosis can result from damage to CN III and slurred speech often occurs from either
damage to several cranial nerves or from damage to the motor strip in the frontal lobe of the
brain.
The nurse is performing an assessment of cranial nerve III. Which testing is appropriate?
a. Pupil constriction
b. Deep tendon reflexes
c. Upper muscle strength
d. Speech and language
ANS: A
CN III is the oculomotor nerve which controls eye movement, pupil constriction, and eyelid
movement.
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 would the nurse
respond?
a. “Caring for your children is a priority. You may not want to ask for help, but you
really 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. “Can you tell me more 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 would 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 patient.
Consulting a psychologist would not be appropriate without obtaining further information
from the client related to current concerns.
A nurse plans care for a 77-year-old client who is experiencing age-related
peripheral sensory perception changes. Which intervention would the nurse include in this
client’s plan of care?
a. Provide a call button that requires only minimal pressure to activate.
b. Write the date on the client’s white board to promote orientation.
c. Ensure that the path to the bathroom is free from clutter.
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 client’s impaired sensory
perception.
After teaching a patient who is scheduled for magnetic resonance imaging (MRI), the nurse
assesses the client’s understanding. Which statement indicates client 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. “My gag reflex will be tested before I can eat or drink anything.”
d. “I can return to my usual activities immediately after the MRI.”
ANS: D
No postprocedure 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 client’s urine would not be
radioactive. The procedure does not impact the client’s gag reflex.
A nurse performs an assessment of pain discrimination on an older adult. The client correctly
identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin.
Which action would the nurse take next?
a. Touch the pin on the same area of the left hand.
b. Contact the primary health care provider with the assessment results.
c. Ask the client about current and past medications.
d. Continue the assessment on the client’s feet and legs.
ANS: A
If testing is begun on the right hand and the client correctly identifies the pain stimulus, the
nurse would 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 client’s medical record.
Medications do not need to be assessed in response to this finding. The nurse would assess the
left hand prior to assessing the feet.
A nurse is teaching a client with cerebellar function impairment. Which statement would the
nurse include in this client’s 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.
Which statement would the nurse include when teaching the assistive personnel (AP) about
how to 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-Fowler position for all meals.”
c. “Make sure the client’s 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 patient who has
cranial nerve II impairment will have decreased visual acuity, so the AP would tell the client
where different food items are on the meal tray. The other options are not appropriate for
client with cranial nerve II impairment.
A nurse prepares a client for lumbar puncture (LP). Which assessment finding would alert the
nurse to contact the primary health care provider?
a. Shingles infection on the client’s back
b. Client is claustrophobic
c. Absence of intravenous access
d. Paroxysmal nocturnal dyspnea
ANS: A
An LP would not be performed if the client has a skin infection at or near the puncture site
because of the risk of cerebrospinal fluid infection. A nurse would want to notify the primary
health care provider if shingles were identified on the client’s back. If a client has shortness of
breath when lying flat, the LP can be adapted to meet the client’s needs. Claustrophobia,
absence of IV access, and paroxysmal nocturnal dyspnea have no impact on whether an LP
can be performed.
A nurse assesses a patient who is recovering from a lumbar puncture (LP). Which
complication of this procedure would alert the nurse to urgently contact the primary health
care provider?
a. Weak pedal pulses
b. Nausea and vomiting
c. Increased thirst
d. Hives on the chest
ANS: B
The nurse would 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.
A nurse assesses a client with an injury to the medulla. Which clinical manifestations would
the nurse expect to find? (Select all that apply.)
a. Decreased respiratory rate
b. Impaired swallowing
c. Visual changes
d. Inability to shrug shoulders
e. Loss of gag reflex
ANS: A, 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 decreased respirations, impaired swallowing, inability to shrug
shoulders, and loss of the gag reflex. The other manifestations are not associated with damage
to the medulla.
An 84-year-old client who is usually alert and oriented experiences an acute cognitive decline. Which of the following factors would the nurse anticipate as contributing to this neurologic change? (Select all that apply.) a. Chronic hearing loss b. Infection c. Drug toxicity d. Dementia e. Hypoxia f. Aging
ANS: B, C, E
Acute client conditions that occur in older adults often cause acute confusion and associated
emotional behaviors. Infection, drug toxicity, and hypoxia are all acute health problems that
can contribute to the client’s cognitive decline. Aging does not cause changes in cognition. If
the client had dementia, he or she would not be alert and oriented. Having a chronic hearing
loss is not a change in the client’s condition.
A nurse assesses a client with a brain tumor. Which newly identified assessment findings would alert the nurse to urgently communicate with the primary health care provider? (Select all that apply.) a. Glasgow Coma Scale score of 8 b. Decerebrate posturing c. Reactive pupils d. Uninhibited speech e. Decreasing level of consciousness
ANS: A, B, E
The nurse would urgently communicate changes in a patient’s neurologic status, including a
decrease in the Glasgow Coma Scale score; abnormal flexion or extension; changes in
cognition or level of consciousness; and pinpointed, dilated, and nonreactive pupils.
A nurse assesses an older client. Which assessment findings would 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.
The nurse is teaching the daughter of a client who has middle-stage Alzheimer disease. The
daughter asks, “Will the sertraline my mother is taking improve her dementia?” How would
the nurse respond about the purpose of the drug?
a. “It will allow your mother to live independently for several more years.”
b. “It is used to halt the advancement of Alzheimer disease but will not cure it.”
c. “It will not improve her dementia but can help control emotional responses.”
d. “It is used to improve short-term memory but will not improve problem solving.”
ANS: C
Drug therapy is not effective for treating dementia or halting the advancement of Alzheimer
disease. However, certain psychoactive drugs may help suppress emotional disturbances and
manage depression, psychoses, or anxiety. Drug therapy will not allow the client with
middle-stage dementia to safely live independently.
A client with early-stage Alzheimer disease is admitted to the hospital with chest pain. Which
nursing action is most appropriate to manage this client’s dementia?
a. Provide animal-assisted therapy as needed.
b. Ensure a structured and consistent environment.
c. Assist the client with activities of daily living (ADLs).
d. Use validation therapy when communicating with the client.
ANS: B
The client who has early Alzheimer disease (AD) does not require assistance with ADLs or
validation therapy. While animal-assisted therapy may be helpful, some health care agencies
do not allow this intervention. Therefore, the most appropriate action is to provide a structured
and consistent environment while the client is hospitalized to prevent worsening of the client’s
symptoms.
The nurse observes a client with late-stage Alzheimer disease eat breakfast. Afterward the
client states, “I am hungry and want breakfast.” What is the nurse’s best response?
a. “I see you are still hungry. I will get you some toast.”
b. “You ate your breakfast 30 minutes ago.”
c. “It appears you are confused this morning.”
d. “Your family will be here soon. Let’s get you dressed.”
ANS: A
Use of validation therapy with clients who have late-stage Alzheimer disease involves
acknowledgment of the client’s feelings and concerns. This technique has proved more
effective in later stages of the disease because reality orientation only increases agitation. The
other statements do not validate the client’s concerns.
The nurse cares for a client with middle-stage (moderate) Alzheimer disease. The client’s
caregiver states, “She is always wandering off. What can I do to manage this restless
behavior?” What is the nurse’s best response?
a. “This is a sign of fatigue. The client would benefit from a daily nap.”
b. “Engage the client in scheduled activities throughout the day.”
c. “It sounds like this is difficult for you. I will consult the social worker.”
d. “The provider can prescribe a mild sedative for restlessness.”
ANS: B
Several strategies may be used to cope with restlessness and wandering. One strategy is to
engage the client in structured activities. Another is to take the client for frequent walks. Daily
naps and a mild sedative will not be as effective in the management of restless behavior.
Consulting the social worker does not address the caregiver’s concern.
The nurse prepares to discharge a client with early to moderate Alzheimer disease. Which
statement to maintain client safety would the nurse include in the discharge teaching for the
caregiver?
a. “Provide periods of exercise and rest for the client.”
b. “Place a padded throw rug at the bedside.”
c. “Provide a highly stimulating environment.”
d. “Install safety locks on all outside doors.”
ANS: D
Clients with early to moderate Alzheimer disease have a tendency to wander, especially at
night. If possible, alarms would be installed on all outside doors to alert family members if the
client leaves. At a minimum, all outside doors should have safety locks installed to prevent the
client from going outdoors unsupervised. The client would be allowed to exercise within his
or her limits, but this action does not ensure his or her safety. Throw rugs are a slip and fall
hazard and would be removed. A highly stimulating environment would likely increase the
client’s confusion.
The nurse is teaching a family caregiver about how best to communicate with the client who
has been diagnosed with Alzheimer disease. Which statement by the caregiver indicates a
need for further teaching?
a. “I will avoid communicating with the client to prevent agitation.”
b. “I should use simple, short sentences and one-step instructions.”
c. “I can try to use gestures or pictures to communicate with the client.”
d. “I will limit the number of choices I provide for the client.”
ANS: A
Communication with the client is important to provide cognitive stimulation. Using short
simple sentences, using gestures and pictures, and limiting choices provided for the client will
help promote communication.
The nurse teaches assistive personnel (AP) about how to care for a client with early-stage
Alzheimer disease. Which statement would the nurse include?
a. “If she is confused, play along and pretend that everything is okay.”
b. “Remove the clock from her room so that she doesn’t get confused.”
c. “Reorient the client to the day, time, and environment with each contact.”
d. “Use validation therapy to recognize and acknowledge the client’s concerns.”
ANS: C
Clients who have early-stage Alzheimer disease would be reoriented frequently to person,
place, and time. The AP would reorient the client and not encourage the client’s delusions.
The room would have a clock and white board with the current date written on it. Validation
therapy is used with late-stage Alzheimer disease.
The primary health care provider prescribes donepezil for a client diagnosed with early-stage
Alzheimer disease. What teaching about this drug will the nurse provide for the client’s family
caregiver?
a. “Monitor the client’s temperature because the drug can cause a low grade fever.”
b. “Observe the client for nausea and vomiting to determine drug tolerance.”
c. “Donepezil will prevent the client’s dementia from progressing as usual.”
d. “Report any client dizziness or falls because the drug can cause bradycardia.”
ANS: D
Donepezil is a cholinesterase inhibitor that may temporarily slow cognitive decline for some
clients but does not alter the course of the disease. The family caregiver would want to
monitor the client’s heart rate and report any incidence of dizziness or falls because the drug
can cause bradycardia. It does not typically cause fever or nausea/vomiting.
After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife’s
understanding. Which statement by the client’s wife indicates that she correctly understands
changes associated with this disease?
a. “His masklike face makes it difficult to communicate, so I will use a white board.”
b. “He should not socialize outside of the house due to uncontrollable drooling.”
c. “This disease is associated with anxiety causing increased perspiration.”
d. “He may have trouble chewing, so I will offer bite-sized portions.”
ANS: D
Because chewing and swallowing can be problematic, small frequent meals and a supplement
are better for meeting the client’s nutritional needs. A masklike face and drooling are common
in clients with Parkinson disease. The client would be encouraged to continue to socialize and
communicate as normally as possible. The wife should understand that the client’s masklike
face can be misinterpreted and additional time may be needed for the client to communicate
with her or others. Excessive perspiration is also common in clients with Parkinson disease
and is associated with the autonomic nervous system’s response.
The nurse plans care for a client with Parkinson disease. Which intervention would the nurse
include in this client’s plan of care?
a. Restrain the client to prevent falling.
b. Ensure that the client uses incentive spirometry.
c. Teach the client pursed-lip breathing techniques.
d. Keep the head of the bed at 30 degrees or greater
ANS: D
Elevation of the head of the bed will help prevent aspiration. The other options will not
prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do
these interventions address any of the complications of Parkinson disease. Pursed-lip
breathing increases exhalation of carbon dioxide; incentive spirometry expands the lungs. The
client should not be restrained to prevent falls. Other less restrictive interventions should be
used to maintain client safety.
A nurse teaches assistive personnel (AP) about how to care for a client with Parkinson
disease. Which statement would the nurse include as part of this teaching?
a. “Allow the client to be as independent as possible with activities.”
b. “Assist the client with frequent and meticulous oral care.”
c. “Assess the client’s ability to eat and swallow before each meal.”
d. “Schedule appointments early in the morning to ensure rest in the afternoon.”
ANS:A
Clients with Parkinson disease do not move as quickly and can have functional problems. The
client would be encouraged to be as independent as possible and provided time to perform
activities without rushing. Although oral care is important for all clients, instructing the UAP
to provide frequent and meticulous oral is not a priority for this client. This statement would
be a priority if the client was immune-compromised or NPO. The nurse would assess the
client’s ability to eat and swallow; this would not be delegated. Appointments and activities
would not be scheduled early in the morning because this may cause the client to be rushed
and discourage the client from wanting to participate in activities of daily living.
A client diagnosed with Parkinson disease will be starting ropinirole for symptom control.
Which statement by the client indicates a need for further teaching?
a. “This drug should help decrease my tremors and help me move better.”
b. “I need to change positions slowly to prevent dizziness or falls.”
c. “I should take the drug at the same time each day for the best effect.”
d. “I know the drug will probably make help me prevent constipation.”
ANS: D
Although ropinirole is a dopamine agonist and mimics dopamine to promote movement, it
does not work to prevent constipation. This class of drugs can cause orthostatic hypotension
and should be taken at the same time every day.
A nurse is teaching a client who experiences migraine headaches and is prescribed
propranolol. Which statement would the nurse include in this client’s teaching?
a. “Take this drug only when you have symptoms indicating the onset of a migraine
headache.”
b. “Take this drug as prescribed, even when feeling well, to prevent vascular changes
associated with migraine headaches.”
c. “This drug will relieve the pain during the aura phase soon after a headache has
started.”
d. “This drug will have no effect on your heart rate or blood pressure because you are
taking it for migraines.”
ANS: B
Propranolol is a beta-adrenergic blocker which is prescribed as prophylactic treatment to
prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure
will also be affected, and the client would monitor these side effects. The other responses do
not discuss appropriate uses of this drug.
The nurse assesses a client who has a history of migraines. Which symptom would the nurse
identify as an early sign of a migraine with aura?
a. Vertigo
b. Lethargy
c. Visual disturbances
d. Numbness of the tongue
ANS: C
Early warning of impending migraine with aura usually consists of visual changes, flashing
lights, or diplopia. The other symptoms are not associated with an impending migraine with
aura.
The nurse assesses a client with a history of epilepsy who experiences stiffening of the
muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of
all extremities. How would the nurse document this type of seizure?
a. Atonic
b. Myoclonic
c. Absence
d. Tonic-clonic
ANS: D
Seizure activity that begins with stiffening of the arms and legs, followed by loss of
consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. An
atonic seizure presents as a sudden loss of muscle tone followed by postictal confusion. A
myoclonic seizure presents with a brief jerking or stiffening of extremities that may occur
singly or in groups. Absence seizures present with automatisms, and the client is unaware of
his or her environment.
