NERVOUS SYSTEM

Prepared by: Prof. Mike Chavez RN, USRN

1. A client injured in a train derailment is admitted to an acute care facility with a suspected
dysfunction of the lower brain stem. The nurse should monitor this client closely for:
a. Hypoxia b. fever
c. visual disturbance d. gait alteration

2. Family members would like to bring in birthday cake for a client with nerve damage. What
cranial nerve needs to be functioning so the client can chew?
a. Cranial nerve II b. Cranial nerve V
c. Cranial nerve IX d. Cranial nerve X

3. During recovery from a cerebrovascular accident (CVA), a client is given nothing by mouth, to
help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse
assesses the client's swallowing ability once each shift. This assessment evaluates:
a. cranial nerves I and II c. cranial nerves VI and VIII
b. cranial nerves III and V d. cranial nerves IX and X

4. The nurse formulates a nursing diagnosis of Risk for imbalanced body temperature for a client
who suffers a cerebrovascular accident (CVA) after surgery. When developing expected
outcomes, the nurse incorporates assessment of the client's temperature to detect
abnormalities. The thermoregulatory centers are located in which part of the brain?
a. Pons b. Cerebellum
c. Temporal lobe d. Hypothalamus

5. If a client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the
nurse would anticipate that the client has problems with:
a. body temperature control c. visual acuity
b. balance and equilibrium d. thinking and reasoning

6. A client who was trapped inside a car for hours after a head-on collision is rushed to the
emergency department with multiple injuries. During the neurologic examination, the client
responds to painful stimuli with decerebrate posturing. This finding indicates damage to which
part of the brain?
a. Diencephalon b. Medulla
c. Midbrain d. Cortex

7. What is the function of cerebrospinal fluid (CSF)?

a. It cushions the brain and spinal cord
b. It acts as an insulator to maintain a constant spinal fluid temperature
c. It acts as a barrier to bacteria
d. It produces cerebral neurotransmitters

8. The nurse is performing a mental status examination on a client diagnosed with subdural
hematoma. This test assesses which of the following?
a. Cerebellar function b. Intellectual function
c. Cerebral function d. Sensory function

9. The nurse is evaluating a client's cranial nerves during a routine examination. To assess the
function of cranial nerve XI (spinal accessory), the nurse should instruct the client to:
a. smell and identify a nonirritating, aromatic odor
b. read an eye chart from a distance of 20′
c. elevate the shoulders, both with and without resistance
d. stick out the tongue and move it rapidly from side to side and in and out
10. A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing
diagnosis takes highest priority?
a. Disturbed sensory perception (visual) related to neurologic trauma
b. Self care deficient: Feeding related to neurologic trauma
c. Impaired verbal communication related to confusion
d. Risk for injury related to neurologic deficit

11. When communicating with a client who has sensory (receptive) aphasia, the nurse should:
a. Allow time for the client to respond c. Give the client a writing pad
b. Speak loudly and articulate clearly d. Use short, simple sentences

12. Damage to which area of the brain results in receptive aphasia?

a. Parietal lobe b. Occipital lobe
c. Temporal lobe d. Frontal lobe

13. The nurse observes a comatose client's response to painful stimuli. The client exhibits extended
and pronated arms, flexed wrists with palms facing backward, and rigid legs extended with
plantar flexion. This type of posturing as a response to pain indicates which of the following?
a. Dysfunction in the cerebrum c. Dysfunction in the brain stem
b. Risk for increased intracranial pressure d. Dysfunction in the spinal column

14. To assess a client's cranial nerve function, the nurse should:

a. Assess hand grip c. Assess arm extension
b. Assess orientation to person, time, and place d. Assess winking

15. Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's
disease?
a. Pain related to vertigo
b. Imbalanced nutrition: Less than body requirements related to nausea and vomiting
c. Risk for deficient fluid volume related to vomiting
d. Risk for injury related to vertigo

16. If a client experienced a cerebrovascular accident (CVA) that damaged the thalamus, the nurse
would anticipate that the client has problems with:
a. Pain sensation b. Breathing pattern
c. Wakefulness d. Thinking and reasoning

17. A nurse is caring for a client with intracranial aneurism. The nurse interprets that which of the
following is related to dysfunction of cranial nerve III?
a. Mild drowsiness c. Slight slurring of speech
b. Less frequent spontaneous speech d. Ptosis of the left eyelid

18. A nurse is assigned to a client who is a new admission for the treatment of a frontal lobe brain
tumor. Which history offered by the family members would be anticipated by the nurse as
associated with the diagnosis when communicated?
a. "My partner's breathing rate is usually below 12"
b. "I find the mood swings and the change from a calm person to being angry all the
time hard to deal with"
c. "It seems our sex life is nonexistent over the past 6 months"
d. "In the morning and evening I hear complaints that reading is next to impossible from
blurred print"

19. A client with seizures disorder comes to the physician's office for a routine checkup. Knowing
that the client takes phenytoin (Dilantin) to control seizures, the nurse assesses for which
common adverse drug reaction?
a. Excessive gum tissue growth b. Drowsiness
c. Hypertension d. Tinnitus
20. A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate
nursing response is to:
a. hold the client's arm still to keep him from hitting anything
b. carefully move him to a flat surface and turn him on his side
c. allow him to remain in the chair but move all objects out of his way
d. place an oral airway in his mouth to maintain an open airway

21. A client with epilepsy is having a seizure. During the active seizure phase, the nurse should:
a. place the client on his back, remove dangerous objects, and insert a bite block
b. place the client on his side, remove dangerous objects, and insert a bite block
c. place the client on his back, remove dangerous objects, and hold down his arms
d. place the client on his side, remove dangerous objects, and protect his head

22. A client is having tonic-clonic seizures. What should the nurse do first?
a. Elevate the head of the bed c. Place a tongue blade in the client's mouth
b. Restrain the client's arms and legs d. Take measures to prevent injury

23. Shortly after admission to an acute care facility, a client with a seizure disorder develops status
epilepticus. The nurse should anticipate that the doctor will order which of the following
medication to treat this medical emergency?
a. Epinephrine b. Dilantin
c. Valium d. Calcium gluconate

24. The physician prescribes diazepam (Valium), 10 mg I.V., for a client experiencing status
epilepticus. Which statement about I.V. diazepam is true?
a. It may be mixed with other drugs in an infusion.
b. It should be administered in a small vein to minimize irritation.
c. It rarely causes adverse reactions.
d. It should be administered no faster than 5 mg/minute in an adult.

25. A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse expects
to administer which neuromuscular blocking agent?
a. succinylcholine (Anectine) c. pancuronium (Pavulon)
b. vecuronium (Norcuron) d. atracurium (Tracrium)

26. A client with Parkinson's disease visits the physician's office for a routine checkup. The nurse
notes that the client takes Benztropine (Cogentin), 0.5 mg P.O. daily, and asks when the client
takes the drug each day. Which response indicates that the client understands when to take
Benztropine?
a. "I take the medication when I get up in the morning"
b. "I take the medication with a meal"
c. "I take the medication after a meal"
d. "I take the medication at bedtime"

27. Which nursing diagnosis takes highest priority for a client with Parkinson's crisis?
a. Imbalanced nutrition: Less than body requirements
b. Ineffective airway clearance
c. Impaired urinary elimination
d. Risk for injury

28. The nurse is assigned to a client with Parkinson's disease. Which findings would the nurse
anticipate?
a. Intention tremors and urgency with voiding
b. Echolalia and a shuffling gait
c. Muscle spasm and a bent over posture
d. Unintentional tremor and jerky movement of the elbows
29. The nurse is caring for a client with Parkinson's disease. The client spends over 1 hour to dress
for scheduled therapies. What is the most appropriate action for the nurse to take in this
situation?
a. Ask family members to dress the client
b. Encourage the client to dress more quickly
c. Allow the client the time needed to dress
d. Demonstrate methods on how to dress more quickly

30. The nurse is assessing a 38-year-old client diagnosed with multiple sclerosis. Which of the
following symptoms would the nurse expect to find?
a. Vision changes b. Absent DTR
c. Tremors at rest d. Flaccid muscles

31. A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-
surgical unit. Which equipment is most important for the nurse to keep at the client's bedside?
a. Sphygmomanometer c. Nasal cannula and oxygen
b. Padded tongue blade d. Suction machine with catheters

32. When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should
include which instruction?
a. "Avoid taking daytime naps." c. "Limit your fruit and vegetable intake."
b. "Avoid hot baths and showers." d. "Restrict fluid intake to 1,500 ml/day."

33. The nurse is teaching a client with multiple sclerosis. When teaching the client how to reduce
fatigue, the nurse should tell the client to:
a. take a hot bath c. increase the dose of muscle relaxants
b. rest in an air-conditioned room d. avoid naps during the day

34. A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a
tentative diagnosis of Guillain-Barré syndrome. In this syndrome, polyneuritis leads to
progressive motor, sensory, and cranial nerve dysfunction. On admission, which assessment is
most important for this client?
a. Lung auscultation and measurement of vital capacity and tidal volume
b. Evaluation for signs and symptoms of increased intracranial pressure
c. Evaluation of pain and discomfort
d. Evaluation of nutritional status and metabolic state

35. A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and
requires mechanical ventilation. When the client asks the nurse about the paralysis, how should
the nurse respond?
a. "You may have difficulty believing this, but the paralysis caused by this disease is
temporary."
b. "You'll have to accept the fact that you're permanently paralyzed. However, you won't have
any sensory loss."
c. "It must be hard to accept the permanency of your paralysis."
d. "You'll first regain use of your legs and then your arms."

36. A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most
significant?
a. Warm, dry skin c. Soft, nondistended abdomen
b. Urine output of 40 ml/hour d. Even, unlabored respirations

37. A client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrated.
I can't do anything without help!" This comment best supports which nursing diagnosis?
a. Anxiety b. Powerlessness
c. Ineffective denial d. Risk for disuse syndrome
38. In a client with amyotrophic lateral sclerosis and respiratory distress, which finding is the
earliest sign of reduced oxygenation?
a. Decreased heart rate c. Increased blood pressure
b. Increased restlessness d. Decreased level of consciousness

39. A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder,
the nurse prepares the client for various diagnostic tests. The nurse expects the physician to
order:
a. Electromyography c. Doppler ultrasonography
b. Doppler scanning d. Electroencephalogram

40. The nurse is teaching a client who has facial muscle weakness and has recently been diagnosed
with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by:
a. genetic dysfunction
b. upper and lower motor neuron lesions
c. decreased conduction of impulses in an upper motor neuron lesion
d. a lower motor neuron lesion

41. A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup.
Myasthenia gravis is confirmed by:
a. A positive Tensilon test c. A positive sweat chloride test
b. Kernig's sign d. Brudzinski's sign

42. While reviewing a client's chart, the nurse notices that the client has myasthenia gravis. Which
of the following statements about neuromuscular blocking agents is true for a client with this
condition?
a. The client may be less sensitive to the effects of a neuromuscular blocking agent.
b. Succinylcholine shouldn't be used; pancuronium may be used in a lower dosage.
c. Pancuronium shouldn't be used; succinylcholine may be used in a lower dosage.
d. Pancuronium and succinylcholine both require cautious administration.

43. The physician suspects myasthenia gravis in a client with chronic fatigue, muscle weakness, and
ptosis. Myasthenia gravis is associated with:
a. thyroid disorders b. poor nutrition
c. chemotherapy d. a viral infection

44. A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine (Mestinon),
60 mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews
the client's history. Which preexisting condition would contraindicate the use of pyridostigmine?
a. Ulcerative colitis b. Blood dyscrasia
c. Intestinal obstruction d. Spinal cord injury

45. The nurse is administering neostigmine to a client with myasthenia gravis. Which nursing
intervention should the nurse implement?
a. Give the medication on an empty stomach
c. Schedule the medication before meals
b. Warn the client that he'll experience mouth dryness
d. Administer the medication for complaints of muscle weakness or difficulty swallowing

46. When obtaining the vital signs of a client with multiple traumatic injuries, the nurse detects
bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician
immediately because these findings may reflect which complication?
a. shock b. encephalitis
c. increased intracranial pressure d. status epilepticus
47. After striking his head on a tree while falling from a ladder, a young man is admitted to the
emergency department. He's unconscious and his pupils are nonreactive. Which intervention
would be the most dangerous for the client?
a. Give him a barbiturate c. Perform a lumbar puncture
b. Place him on mechanical ventilation d. Elevate the head of his bed

48. A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the
first postoperative day, the nurse notes absence of a bone flap at the operative site. How should
the nurse position the client's head?
a. Flat c. Elevated no more than 10 degrees
b. Turned onto the operative side d. Elevated 30 degrees

49. The nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP).
Which intervention should the nurse include in the plan of care to reduce ICP?
a. Encourage coughing and deep breathing
b. Position with head turned toward side of brain tumor
c. Administer stool softeners
d. Provide sensory stimulation

50. A young man was running along an ocean pier, tripped on an elevated area of the decking, and
struck his head on the pier railing. According to his friends, "He was unconscious briefly and
then became alert and behaved as though nothing had happened." Shortly afterward, he began
complaining of a headache and asked to be taken to the emergency department. If the client's
intracranial pressure (ICP) is increasing, the nurse would expect to observe which of the
following signs first?
a. Pupillary asymmetry c. Involuntary posturing
b. Irregular breathing pattern d. Declining level of consciousness