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Chapter 67: Assessment of the Neurologic System

MULTIPLE CHOICE
1. In assessing function of cranial nerves (CN), the nurse offers a client toothpaste and
the client can only identify it by smell. The nurse would record that
a. CN I is functional.
b. CN II is partially functional.
c. CN IV is non-functional.
d. CNs are unable to be assessed this way.
ANS: C
Identifying objects by smell indicates that CN I (olfactory nerve) is intact. CN II is the
optic nerve. CN IV is the trochlear nerve.
DIF: Comprehension/Understanding REF: pp. 1778-1780
OBJ: Assessment
MSC: Physiological Integrity Reduction of Risk Potential-System Specific
Assessments
2. The nurse asking a client questions that test orientation would include
a. Can you count backward from 100 by 7s?
b. Do you have any brothers and sisters?
c. What would you do if you lost your house key?
d. What year is this?
ANS: D
Questions that test for orientation relate to person, place, and time. The other options
test for judgment, calculation, and long-term memory.
DIF: Application/Applying REF: p. 1775 OBJ: Intervention
MSC: Physiological Integrity Reduction of Risk Potential-System Specific
Assessments
3. The nurse documents the clients gait as short, accelerating steps with the client
shuffling in a forward-leaning posture and having difficulty starting and stopping. The
nurse would identify this type of gait as
a. ataxic.
b. dystrophic.
c. festinating.
d. parkinsonian.
ANS: D
Parkinsonian gait is short, accelerating steps; shuffling; forward-leaning posture;
flexed head, hips, and knees; and difficulty starting and stopping. An ataxic gait is
staggering and unsteady. A dystrophic gait is with legs far apart, weight shifting from
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side to side (waddling in appearance). A festinating gait is one in which the client
walk on his/her toes at an accelerating pace.
DIF: Comprehension/Understanding REF: p. 1774, Evolve site
OBJ: Assessment
MSC: Physiological Integrity Reduction of Risk Potential-System Specific
Assessments
4. When testing comprehension in a client who is expressively aphasic, the nurse lays
out a pencil, a key, and a ball and then would
a. ask the client to pick up the ball.
b. hold up the key and ask, What do you do with this?
c. point to the pencil and ask, What is this?
d. point to the ball and ask What can this be used for?
ANS: A
Clients who are expressively aphasic cannot organize speech or language to
communicate, but they can understand. The client picks up the ball when asked, so the
nurse knows that the client understood the request and identified the ball and picked it
up.
DIF: Analysis/Analyzing REF: p. 1776 OBJ: Assessment
MSC: Physiological Integrity Reduction of Risk Potential-System Specific
Assessments
5. When the nurse asks the client to raise the eyebrows and grimace or puff the
cheeks, the nurse would be assessing the function of cranial nerve
a. VII.
b. VIII.
c. IX.
d. X.
ANS: A
CN VII controls facial expressions and symmetry of the facial features. CN VIII, the
vestibulocochlear or acoustic nerve, is involved with hearing and balance. CN IX
(glossopharyngeal nerve) controls swallow and gag reflexes and supplies some taste.
CN X is the vagus nerve and is involved in regulation of heart rate and GI motility.
DIF: Analysis/Analyzing REF: pp. 1778-1780
OBJ: Assessment
MSC: Physiological Integrity Reduction of Risk Potential-System Specific
Assessments
6. A nurse working on a rehabilitation unit is assessing a new admission, a client with
a stable spinal cord injury. The nurse notes that the client is unable to shrug the
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shoulders. This finding indicates to the nurse that the level of spinal cord injury in the
client is
a. C4-5.
b. C8-T1.
c. L1-3.
d. S1-2.
ANS: A
Shoulder elevation is controlled by the supraspinous muscle, which is innervated with
nerves arising from the C4-5 area. Alterations at C8-T1 would produce an inability to
spread the fingers. An alteration at L1-3 would prevent the client from raising the
knees to the chest. And alterations at S1-2 would prevent the client from being able to
press down with the foot.
DIF: Comprehension/Understanding REF: p. 1782 OBJ: Assessment
MSC: Physiological Integrity Reduction of Risk Potential-System Specific
Assessments
7. Neurologic examination reveals that a client has intact, functioning cranial nerves
(CNs) III through XII. The nurse would conclude that the client has normal function
of the
a. brain stem.
b. cerebellum.
c. cerebrum.
d. spinal cord.
ANS: A
CNs III through XII arise in the brain stem. Testing their function provides
information about the brain stem and related pathways.
DIF: Comprehension/Understanding REF: p. 1777 OBJ: Assessment
MSC: Physiological Integrity Reduction of Risk Potential-System Specific
Assessments
8. In assessing the function of CNs III, IV, and VI, the nurse would ask the client to
a. look straight ahead for examination with an ophthalmoscope.
b. move the eyes in six directions.
c. read a newspaper.
d. shut the eyes tightly.
ANS: B
CNs III, IV, and VI coordinate to control eye movements in all six cardinal directions
of gaze.
DIF: Analysis/Analyzing REF: pp. 1778-1780
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OBJ: Assessment
MSC: Physiological Integrity Reduction of Risk Potential-System Specific
Assessments
9. If the client has adequate proprioception, the nurse would know that the client can
a. bend over at a 90-degree angle and return to ab upright position.
b. stand steady with feet together.
c. touch nose with eyes closed.
d. touch top lip with tip of tongue.
ANS: C
Proprioception is the sense of body position.
DIF: Knowledge/Remembering REF: p. 1781 OBJ: Assessment
MSC: Physiological Integrity Reduction of Risk Potential-System Specific
Assessments
10. In assessing a client for Babinskis reflex, the nurse would
a. press thumbs under the ball of the clients foot.
b. scrape the sole with a blunt object from heel toward great toe.
c. tap the sole with a percussion hammer at mid-arch.
d. tickle the sole of the clients foot with a fingernail.
ANS: B
Babinskis reflex is tested by gently scraping the sole of the foot with a blunt-ended
object. A normal response is plantiflexion of the toes. An abnormal response
(presence of Babinskis reflex) is dorsiflexion of the great toe and, often, fanning of the
other toes.
DIF: Application/Applying REF: pp. 1783-1784
OBJ: Assessment
MSC: Physiological Integrity Reduction of Risk Potential-System Specific
Assessments
11. A client had a lumbar puncture and the report came back as follows: glucose 70
mg/dl, protein 32 mg/dl, opening pressure 230 mm H2O, cells 100. The priority action
by the nurse would be to
a. administer IV diuretics.
b. monitor the clients blood pressure every 15 minutes for an hour.
c. place the client in Trendelenburg position.
d. prepare to administer IV antibiotics.
ANS: D
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The high opening pressure (normal 70-180 mm H2O) and the high number of cells
(normal 1-5) indicate infection in the CSF or brain, which can be life-threatening.
Treatment is immediate IV antibiotics. The other two findings are normal.
DIF: Analysis/Analyzing
REF: Table: Normal Cerebrospinal Fluid (CSF) and Significance of Abnormal
Values, Evolve site OBJ: Intervention
MSC: Safe, Effective Care Environment Management of Care-Establishing Priorities
12. In assessing the cause of the decreased level of consciousness in a client in a
coma, the diagnostic procedure that would provide the most accurate information is
a. computed tomography (CT) scan.
b. detailed history of the accident.
c. physical examination.
d. skull x-ray film.
ANS: A
The primary purpose of CT scanning is to detect intracranial bleeding, space-
occupying lesions, cerebral edema, and shifts of brain structures, which all could help
explain the loss of consciousness. The history of the accident can give clues as to the
nature of the injury, but will not be specific. The physical examination cannot
pinpoint bleeding, lesions, cerebral edema, or shifting in structures in the brain. The x-
ray is a useful tool to look for bony abnormalities and neoplasms.
DIF: Comprehension/Understanding REF: pp. 1785-1787
OBJ: Assessment
MSC: Physiological Integrity Physiological Adaptation-Diagnostic Tests
13. During a lumbar puncture on a client in the lateral recumbent position, the
physician remarks that the opening pressure is normal. The nurse would interpret this
to mean that the pressure is
a. below 5 mm Hg.
b. between 6 and 13 mm Hg.
c. between 14 and 25 mm Hg.
d. above 25 mm Hg.
ANS: B
The normal opening pressure with the client in the lateral recumbent position is 6 to
13 mm Hg.
DIF: Comprehension/Understanding
REF: Table: Normal Cerebrospinal Fluid (CSF) and Significance of Abnormal
Values, Evolve site OBJ: Assessment
MSC: Physiological Integrity Physiological Adaptation-Laboratory Values
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14. A client with a brain tumor is scheduled for a spiral CT scan. Which of these
factors, if present in the clients history, would affect the nurses preparation for the
scan?
a. The client has periods of paresthesia in the hands.
b. The client is allergic to seafood and iodine.
c. The client is having trouble remembering recent events.
d. The client takes an anticonvulsant medication on a regular basis.
ANS: B
The nurse should explain that a contrast agent may be used. Because some agents are
iodine-based, the nurse asks whether the client has allergies to iodine or contrast
material.
DIF: Application/Applying REF: pp. 1785-1787
OBJ: Intervention
MSC: Physiological Adaptation Reduction of Risk Potential-Potential for
Complications of Diagnostic Tests/Treatments/Procedures
15. The nurse would point out to a client that the advantage of magnetic resonance
spectroscopy (MRS) is that the procedure
a. assesses markers for neurodegenerative diseases.
b. can be used during pregnancy.
c. provides detailed images of bone tissue.
d. uses only small doses of radiation.
ANS: A
MRS can detect abnormal amounts of chemicals or molecules that are not normally
present and that are markers associated with specific neurodegenerative diseases.
DIF: Comprehension/Understanding REF: p. 1788 OBJ: Intervention
MSC: Physiological Integrity Physiological Adaptation-Diagnostic Tests
16. Which confidence shared by a female client would alter the decision to use
magnetic resonance imaging (MRI) as a diagnostic modality?
a. I was too embarrassed to tell my doctor that Ive had my breasts enlarged.
b. I didnt tell my doctor that Ive had my stomach stapled.
c. My doctor would think Im silly to have had a tummy tuck, so I didnt tell him.
d. No one knows I wear dentures, not even my husband. My doctor doesnt either.
ANS: B
Before the MRI study, the client should remove all objects containing metal. If the
stomach stapling left metal implanted in the clients abdomen, it would preclude the
use of the MRI.
DIF: Analysis/Analyzing REF: pp. 1787-1788
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OBJ: Assessment
MSC: Safe, Effective Care Environment Safety and Infection Control-Safe Use of
Equipment
17. The nurse would explain to a client scheduled for an electroencephalogram (EEG)
that an EEG
a. assesses for the presence of solid masses in the brain.
b. measures the adequacy of cerebral perfusion.
c. records cerebral blood flow patterns.
d. traces superficial electrical activity of the cerebral cortex.
ANS: D
The EEG records the electrical activity of the cerebral cortex on a moving piece of
paper. It is used especially to assess seizure disorders. It is also used as a proof of
death when the picture is clouded with a clients use of long-acting sedatives.
DIF: Comprehension/Understanding REF: p. 1788 OBJ: Intervention
MSC: Physiological Integrity Physiological Adaptation-Diagnostic Tests
18. A client with a head injury has had the caloric test performed using ice-cold water.
When the water was injected into the auditory canal, the clients eyes moved slowly
toward the irrigated side and then quickly returned to midline. The nurse would
conclude after watching this reaction that the client
a. has an intact brain stem.
b. has brain death.
c. is likely to arouse within 24 hours.
d. will be permanently deaf.
ANS: A
If brain stem function is intact, the eyes move in a conjugate fashion slowly toward
the irrigated side and then quickly move back to midline.
DIF: Comprehension/Understanding REF: p. 1790 OBJ: Assessment
MSC: Physiological Integrity Reduction of Risk Potential-System Specific
Assessments
19. The nurse is having a client sign the informed consent form before having an
electromyography (EMG). What is the most appropriate response by the nurse when
the client says The doctor will use little needles to take samples to send to the lab.
a. Agree and have the client sign the form.
b. Ask if the client has any questions before signing.
c. Request the physician re-educate the client.
d. Tear up the consent form because now it is invalid.
ANS: C
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This client does not understand the procedure of EMG, which uses small needle-like
electrodes inserted into muscles to measure muscle action potentials. The client is
describing a muscle biopsy. The physician needs to return and re-educate the client,
who can then sign the same consent form once the client understands the procedure.
DIF: Application/Applying REF: p. 1790 OBJ: Intervention
MSC: Safe, Effective Care Environment Management of Care-Informed Consent
20. A nurse assessing a clients neurologic function. Which assessment is specifically
added for the client who is suspected to have a spinal cord injury?
a. Bowel and bladder function
b. Cranial nerve function
c. Motor and sensory function
d. Pathologic reflexes
ANS: A
All options are part of a detailed neurologic assessment. However, for the client with
suspected spinal cord injury, as assessment of bowel and bladder function is needed
for both location and degree of injury.
DIF: Analysis/Analyzing REF: p. 1774 OBJ: Assessment
MSC: Physiological Integrity Reduction of Risk Potential-System Specific
Assessments
Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.
Some material was previously published.