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Chapter 43: Assessment of the Nervous System

Test Bank
MULTIPLE CHOICE
1. The nurse assesses a client who has trauma to the cerebrum. Which clinical manifestation

does the nurse expect to observe?
Poor coordination
Memory loss
Hyperthermia
Slurred speech

a.
b.
c.
d.

ANS: B

The cerebrum is the largest part of the brain and controls intelligence, creativity, and memory.
Poor coordination, hyperthermia, and slurred speech are caused by other parts of the brain.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
2. The nurse is assessing a client with a frontal lobe brain injury. Which clinical manifestation

does the nurse expect to see?
Inability to interpret taste sensations
Inability to interpret sound
Impaired judgment
Impaired learning

a.
b.
c.
d.

ANS: C

The frontal lobe is responsible for many functions, including judgment, reasoning, voluntary
eye movement, and motor functions. The other clinical manifestations are not associated with
the frontal lobe.
DIF: Cognitive Level: Knowledge/Remembering
REF: Table 43-1, p. 907
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
3. The nurse is planning to provide discharge teaching related to cardiac medications to a client

who has experienced damage to the left temporal lobe of the brain. What does the nurse do to
assist the client to understand the content of the instruction?
a. Use a larger print size for written materials.
b. Ensure that the client is wearing glasses.
c. Point out the color of the medication.
d. Sit on the client’s right side.
ANS: D

The temporal lobe contains the auditory center for sound interpretation. The client’s hearing
will be impaired in the left ear. The nurse should sit on the client’s right side and speak to the
right ear. The other interventions do not address the client’s left temporal lobe damage.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Teaching/Learning 6. d. Which instruction does the nurse provide to promote client safety? “Walk barefoot only in your home.” “Look at the placement of your feet when walking. predisposing the client to falls. the nurse notes that the client has a hypoactive response to a test of deep tendon reflexes. The nurse is discharging an 80-year-old client with diminished touch sensation. Consult a psychiatrist to treat the client’s hospital-acquired depression. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process) MSC: Integrated Process: Nursing Process (Implementation) 5. Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination.” a. Assist the client with ambulation.MSC: Integrated Process: Teaching/Learning 4. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) . b. ANS: C Older clients with decreased sensation are at risk of injury from the inability to sense changes in terrain when walking. The other interventions do not address the client’s problem.” “Put throw rugs at the foot of your bed for cushioning. d. Which is the best nursing action? Promote a quiet atmosphere for sleep and rest to treat the client’s sleep deprivation. ANS: A The older adult experiences certain neurologic changes associated with aging. Massage the client’s legs. b. b. d. Explain to the family that this is a normal age-related decline in mental processing. A client admitted the previous day for a suspected neurologic disorder becomes increasingly lethargic. The other interventions are inappropriate. Complete a full neurologic assessment and notify the neurologist. Apply elastic support hose. The nurse or assistive personnel should assist this client with ambulation to prevent injury. ANS: D A change in the client’s level of consciousness (LOC) is the first indication of a decline in central neurologic functioning. To compensate for this loss. c. Bath water that is too warm places the client at risk for thermal injury. After performing a physical assessment on a 75-year-old client. Elevate the client’s lower extremities. c.” “Bathe in warm water to increase your circulation. The nurse should conduct a thorough assessment and then should notify the neurologist (or other provider). Throw rugs can slip and increase fall risk. a. c. The client also should wear sturdy shoes for ambulation. the client is instructed to look at the placement of her or his feet when walking. Which intervention does the nurse include in this client’s plan of care? a.

but rather a higher level of cognition.MSC: Integrated Process: Nursing Process (Analysis) 7. ANS: B Asking clients about certain facts from the past that can be verified assesses remote. a client demonstrates a positive Romberg’s sign with eyes closed. The other statements indicate immediate and recent memory. b. memory. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment) . c. Which clinical manifestation does the nurse expect to see? Bilateral hypoactive reflexes Bilateral hyperactive reflexes Asymmetric reflex response Bilateral ankle clonus a. d. c.” “Apple. ANS: A Long-standing diabetes mellitus causes peripheral neuropathy. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Analysis) 9. b. Which statement by the client confirms that remote memory is intact? “Mary had a little lamb whose fleece was white as snow. Which condition does the nurse associate with this finding? Difficulty with proprioception Peripheral motor disorder Impaired cerebellar function Positive pronator drift a. The nurse is assessing a client’s remote memory. d. Hypoactive responses or no response to stimulation of deep tendon reflexes is one manifestation of diabetes-induced peripheral neuropathy. in Johnstown Community Hospital. d. 1967. Other responses are not related to complications of diabetes mellitus. The nurse is assessing the deep tendon reflexes of a client with long-standing diabetes mellitus. and pencil are the words you just stated.” a. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction in Risk Potential—System-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment) 8. or longterm. The other options do not explain a positive Romberg’s sign.” “I was born on April 3. c. ANS: A The client who sways with eyes closed (positive Romberg’s sign) but not with eyes open most likely has a disorder of proprioception and uses vision to compensate for it. During a neurologic examination. The client’s ability to make up a rhyme tests not memory.” “My sister brought me to the clinic for this appointment. b. but not with eyes open. chair.

The nurse notes that the client’s right pupil appears dilated. with a sluggish pupillary response to light. Diabetes mellitus and oral glycemic reducing agents c. Decorticate posturing b. a client asks.” b. “Deep breathing will keep you relaxed and will lower the seizure threshold. The physician. “Why will I be asked to take deep breaths during the procedure?” How does the nurse respond? a. The nurse is evaluating a client’s physical assessment with the medical history and treatment plan. The pupillary reaction to light is slowed by the use of eyedrops for glaucoma.10.” c. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Communication and Documentation 11. Decerebrate posturing c. The client is asked to breathe deeply 20 to 30 times for 3 minutes. the charge nurse. which is seen with interruption in the corticospinal pathway. The other responses are not appropriate. Before electroencephalography. During a neurologic assessment of a client. Glaucoma and intraocular pressure–reducing eyedrops d. The other disorders and treatments do not correlate with the clinical assessment. the nurse notes that the client’s arms. “Deep breathing will make you hypoxemic. and other health care team members should be notified immediately of this change in status. wrists. How does the nurse document these findings? a. “Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity. “Hyperventilation causes cerebral vasodilatation and increases the likelihood of seizure activity. Coronary artery disease and beta blockers b. This finding is abnormal and is a sign that the client’s condition has deteriorated.” ANS: B Hyperventilation produces cerebral vasoconstriction and alkalosis. and fingers have become flexed. DIF: Cognitive Level: Application/Applying or higher REF: N/A . The other two options are inaccurate. Which disorder and related treatment does this physical finding correlate with? a. especially if only one eye is being treated. Spinal cord degeneration ANS: A The client is demonstrating decorticate posturing. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Analysis) 12. which lowers the seizure threshold. Myopia and corrective laser surgery ANS: C Clients with glaucoma who are being treated with eyedrops have unequal pupils.” d. which increases the likelihood of seizure activity. Atypical hyperreflexia d. and internal rotation and plantar flexion of the legs are evident. Decerebrate posturing consists of external rotation and extension of the extremities.

c. Perform a funduscopic examination. The nurse checks the extremity for adequate circulation by noting skin color and temperature. ANS: A Cerebral angiography is performed by threading a catheter through the femoral or brachial artery. The other conditions would not affect the angiography. a. d. Which intervention does the nurse implement? Check the right lower extremity pulses. c. In some cases. Clients usually are on bedrest. therefore orthostatic blood pressure cannot be performed. the client may need to be medicated with antihistamines or steroids before the test is given. presence and quality of pulses distal to the injection site. The nurse is caring for a client who had a computed tomography (CT) scan of the head with contrast medium. Apply a pressure dressing to the site of injection. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control— Accident/Injury Prevention) MSC: Integrated Process: Nursing Process (Assessment) 15. The extremity is kept immobilized after the procedure. b. The nurse is caring for a client post-cerebral angiography via the client’s right femoral artery. d. Which priority intervention does the nurse implement? Maintain bedrest with the head of the bed elevated less than 30 degrees. c. and capillary refill. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Assessment) 14. ANS: B Allergies to iodine and/or shellfish need to be explored because the client may have a similar reaction to the dye used in the procedure. Assess the client’s gag reflex. Which question is a priority at this time? “Have you had a recent blood transfusion?” “Do you have allergies to iodine or shellfish?” “Do you have a history of urinary tract infections?” “Do you currently use oral contraceptives?” a. a. The client is given analgesics but not conscious sedation. Measure orthostatic blood pressure. b. ANS: C . Maintain sedation for 8 hours postprocedure. therefore the client’s gag reflex would not be compromised.TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Teaching/Learning 13. b. d. The funduscopic examination would not be affected by cerebral angiography. Increase fluid intake after the procedure. The nurse is preparing a client for magnetic resonance angiography.

“You seem distressed.” “Remove your dentures and any metal before the test begins.If a contrast medium is used. The test does not require MRI. “I am worried I will not be able to care for my young children. “Our community has resources that may help you with some household tasks so you have energy to care for your children. Contrast medium also may act as a diuretic.” “Drink at least 3 liters of fluid during the 24 hours after the test. You may not want to ask for help. b. c. so metal does not have to be removed. An intrauterine device and an AV graft do not contain any metal. ANS: A Caffeine-containing liquids and foods are central nervous system stimulants and may alter the test results.” a. b.” c. 921 TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Planning) 17. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Nursing Process (Planning) 18. Contrast is injected through a peripheral IV.” “Do not take your cardiac medication on the morning of the test. therefore the client does not need to increase fluid intake. resulting in the need for fluid replacement. The nurse is obtaining the health history of a client scheduled for magnetic resonance imaging (MRI). d. Which priority instruction or precaution does the nurse teach a client who is scheduled for a positron emission tomography scan of the brain? “Avoid caffeine-containing substances for 12 hours before the test. DIF: Cognitive Level: Comprehension/Understanding REF: p. The client should take cardiac medications as prescribed. intravenous fluid may be given to promote excretion of the contrast medium. No contrast is used. ANS: B Metal devices such as pacemakers and prostheses interfere with the accuracy of the image and can become displaced by the magnetic force generated by an MRI procedure. A female client with deteriorating neurologic function states. The client will not be sedated for the procedure and will not require bedrest. c. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Implementation) 16. but you have to.” How does the nurse respond? a. “Caring for your children is a priority.” b. d. Would you like to talk to a psychologist about adjusting to your changing status?” . Which condition requires the nurse to cancel the MRI? Amputated leg Internal insulin pump Intrauterine device Atrioventricular (AV) graft a.

or liver failure should not interfere with the client having this test. physical impairment related to illness can be expected. so we can see if we can do something to make adjustments. Use a clock and a calendar to orient and minimize onset of dementia. peptic ulcers. they may not be appropriate for the client. Which condition in the client’s history causes the nurse to contact the provider before the test takes place? a. The nurse should tell the client what is or is not a priority for her. Smoking history c. However. b. Providing opportunities for hazard-free ambulation will maintain strength and mobility (and ensure safety). A client is scheduled for a single-photon emission computed tomography test. “My urine will be radioactive for the next 48 hours. ANS: C Dementia and confusion are not common phenomena in older adults. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication) MSC: Integrated Process: Communication and Documentation 19. Having a history of smoking. Peptic ulcers b. Provide a call button that requires only minimal pressure to activate. “I need to stay away from heavy metals for the next 48 hours. Liver failure d.d. Which statement indicates that the client understands the content of the education? a. The other actions are not a priority. Which nursing action does the nurse implement to ensure the client’s safety? a. d.” ANS: D Investigate specific concerns about situational or role changes before providing additional information. c.” b. This test is contraindicated in women who are breast-feeding.” . Ensure that the path to the bathroom is free from equipment. Consulting a psychologist would not be appropriate. Currently breast feeding ANS: D A SPECT test uses radiopharmaceutical agents that enable radioisotopes to cross the bloodbrain barrier. The nurse is teaching a client before magnetic resonance imaging (MRI). DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Teaching/Learning 21. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort— Mobility/Immobility) MSC: Integrated Process: Nursing Process (Implementation) 20. Admit the client to the room closest to the nursing station. “Give me more information about what worries you. The nurse is planning care for an 83-year-old client with age-related changes to his sensory perception. Although community resources may be available.

DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Teaching/Learning 22. Lumbar puncture is not performed on clients with severely high intracranial pressure. The client can return to normal activities after the test is complete. c. if the distal tract is intact. with eyes closed. d. 925 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Assessment) 24.” ANS: D No postprocedure restrictions are imposed after MRI. Which clinical manifestation assessed by the nurse complicates the lumbar puncture procedure? Normal intracranial pressures Allergy to iodine or shellfish Restlessness and agitation Eating lunch less than 2 hours ago a. While assessing pain discrimination. DIF: Cognitive Level: Comprehension/Understanding REF: p. Touch the pin on the right upper arm. Temperature discrimination is not necessary because the same tract transmits both pain and temperature sensation. a sharp sensation on the right hand when touched with a pin. What action does the nurse take after assessing this new finding? . Touch the pin on the right forearm. The nurse is assessing a client scheduled for a lumbar puncture. “I can return to my usual activities immediately after the MRI.” d. d. assistance may be needed to ensure that the procedure is completed safely. so are the proximal areas. 915 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—System-Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment) 23. the nurse notes the response shown in the photograph below. testing more proximal parts of that extremity is not necessary because. “I must increase my fluids because of the dye used for the MRI. Allergies to iodine and shellfish or eating lunch 2 hours before the procedure have no effect on the procedure. a client correctly identifies. If a client is restless or agitated. ANS: C Clients must be able to hold still during the procedure. c. Touch the right hand with a drop of cold water. Touch the pin on the same area of the left hand. DIF: Cognitive Level: Comprehension/Understanding REF: p. How does the nurse then proceed with the examination? a.c. ANS: A If testing is begun on the hand and the client correctly identifies the pain stimulus. On assessment of the left plantar reflexes of an adult client. b. b.

f.a. DIF: Cognitive Level: Knowledge/Remembering REF: Table 43-2. 908 . e. Anticipate the need for cerebral angiography to determine the cause. p. E. as do portions of cranial nerves VII (facial) and VIII (acoustic). XI (accessory). d. the nurse monitors for which clinical manifestations secondary to damage of cranial nerves that emerge from the medulla? (Select all that apply. b. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Pathophysiology) MSC: Integrated Process: Nursing Process (Implementation) MULTIPLE RESPONSE 1. F Cranial nerves IX (glossopharyngeal). inability to shrug shoulders. The other manifestations are not associated with damage to the medulla. b. Document the finding and continue the assessment. In clients older than 2 years of age. The nurse should notify the health care provider and other members of the health care team because further investigation is warranted. and loss of the gag reflex. In a client with an injury to the medulla.) Loss of smell Impaired swallowing Blink reflex Visual changes Inability to shrug shoulders Loss of gag reflex a. ANS: A This finding is a positive Babinski reflex. d. and XII (hypoglossal) emerge from the medulla. c. X (vagus). c. Relay this abnormal finding to other members of the health care team. Examine the family history for a potential genetic disorder. a positive Babinski reflex is considered abnormal and indicates central nervous system disease. ANS: B. Damage to these nerves causes impaired swallowing.

The nurse is administering a medication to a client that stimulates the sympathetic division of the autonomic nervous system. the rate at which the nurse sets the pump is _____ mL. ANS: 800 200 mL/15 min = x mL/60 min . b. DIF: Cognitive Level: Knowledge/Remembering REF: Table 43-1. ANS: A. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) COMPLETION 1. The other three options do not occur with sympathetic nervous system stimulation. The nurse is assessing a client with a temporal lobe injury. Increased force of contraction e. d. Loss of temperature regulation is seen with damage to the hypothalamus. The temporal lobe also is responsible for the auditory center’s interpretation of sound and complicated memory patterns. Personality changes are related to damage to frontal lobe injury. E Wernicke’s area (language area) is located in the temporal lobe and enables processing of words into coherent thought and understanding of written or spoken words. p. and impaired taste is associated with injury to the parietal lobe.TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 2.9% NS). Decreased force of contraction d. e. D. Decreased respirations ANS: B. c. Decreased heart rate b.) a. the client begins to vomit and an IV is started with normal saline (0. increasing both the heart rate and the force of contraction. Which clinical manifestations correlate with this injury? (Select all that apply. Which clinical manifestations does the nurse monitor for? (Select all that apply. Using an infusion pump that delivers mL/hr. Immediately after a lumbar puncture.) Memory loss Personality changes Loss of temperature regulation Difficulty with sound interpretation Speech difficulties Impaired taste a. f. Increased heart rate c. D Stimulation of the sympathetic nervous system initiates the fight-or-flight response. 907 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 3. The provider orders a 200-mL bolus over 15 minutes.

200 mL/15 min = 800 mL/60 min 15x = 12.000 x = 800 mL DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies— Dosage Calculation) MSC: Integrated Process: Nursing Process (Implementation) .