Question 1

A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting,she gets "really dizzy" and feels like she is going to fall over.The nurse's best response would be:

Accepted Answer

A) "Have you been extremely tired lately?" 
B) "You probably just need to drink more liquids." 
C) "I'll refer you for a complete neurologic examination." 
D) "You need to get up slowly when you've been lying down or sitting."

Question 2

To test for gross motor skill and coordination of a 6-year-old child,which of these techniques would be appropriate? Ask the child to:

Accepted Answer

A) Hop on one foot. 
B) Stand on his head. 
C) Touch his finger to his nose. 
D) Make "funny" faces at the nurse.

Question 3

When taking the health history on a patient with a seizure disorder,the nurse assesses whether the patient has an aura.Which of these would be the best question for obtaining this information?

Accepted Answer

A) "Does your muscle tone seem tense or limp?" 
B) "After the seizure, do you spend a lot of time sleeping?" 
C) "Do you have any warning sign before your seizure starts?" 
D) "Do you experience any color change or incontinence during the seizure?"

Question 4

In a person with an upper motor neuron lesion such as a cerebrovascular accident,which of these physical assessment findings should the nurse expect?

Accepted Answer

A) Hyperreflexia 
B) Fasciculations 
C) Loss of muscle tone and flaccidity 
D) Atrophy and wasting of the muscles

Question 5

While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier,he tells the nurse that he is on a cruise ship and is 30 years old.The nurse knows that this finding is indicative of a(n):

Accepted Answer

A) Great sense of humor. 
B) Uncooperative behavior. 
C) Inability to understand questions. 
D) Decreased level of consciousness.

Question 6

The nurse is testing superficial reflexes on an adult patient.When stroking up the lateral side of the sole and across the ball of the foot,the nurse notices the plantar flexion of the toes.How should the nurse document this finding?

Accepted Answer

A) Positive Babinski sign 
B) Plantar reflex abnormal 
C) Plantar reflex present 
D) Plantar reflex 2+ on a scale from "0 to 4+"

Question 7

While obtaining a health history of a 3-month-old infant from the mother,the nurse asks about the infant's ability to suck and grasp the mother's finger.What is the nurse assessing?

Accepted Answer

A) Reflexes 
B) Intelligence 
C) CNs 
D) Cerebral cortex function

Question 8

During the taking of the health history,a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this finding as:

Accepted Answer

A) Vertigo. 
B) Syncope. 
C) Dizziness. 
D) Seizure activity.

Question 9

The nurse is caring for a patient who has just had neurosurgery.To assess for increased intracranial pressure,what would the nurse include in the assessment?

Accepted Answer

A) CNs, motor function, and sensory function 
B) Deep tendon reflexes, vital signs, and coordinated movements 
C) Level of consciousness, motor function, pupillary response, and vital signs 
D) Mental status, deep tendon reflexes, sensory function, and pupillary response

Question 10

The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)?

Accepted Answer

A) Cerebrum 
B) Cerebellum 
C) CNs 
D) Medulla oblongata

Question 11

The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination.When striking the Achilles heel and quadriceps muscle,the nurse is unable to elicit a reflex.The nurse's next response should be to:

Accepted Answer

A) Ask the patient to lock her fingers and pull. 
B) Complete the examination, and then test these reflexes again. 
C) Refer the patient to a specialist for further testing. 
D) Document these reflexes as 0 on a scale of 0 to 4+.

Question 12

The assessment of a 60-year-old patient has taken longer than anticipated.In testing his pain perception,the nurse decides to complete the test as quickly as possible.When the nurse applies the sharp point of the pin on his arm several times,he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this?

Accepted Answer

A) The patient has hyperesthesia as a result of the aging process. 
B) This response is most likely the result of the summation effect. 
C) The nurse was probably not poking hard enough with the pin in the other areas. 
D) The patient most likely has analgesia in some areas of arm and hyperalgesia in others.

Question 13

A 59-year-old patient has a herniated intervertebral disk.Which of the following findings should the nurse expect to see on physical assessment of this individual?

Accepted Answer

A) Hyporeflexia 
B) Increased muscle tone 
C) Positive Babinski sign 
D) Presence of pathologic reflexes

Question 14

A patient has a severed spinal nerve as a result of trauma.Which statement is true in this situation?

Accepted Answer

A) Because there are 31 pairs of spinal nerves, no effect results if only one nerve is severed. 
B) The dermatome served by this nerve will no longer experience any sensation. 
C) The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve. 
D) A severed spinal nerve will only affect motor function of the patient because spinal nerves have no sensory component.

Question 15

In assessing a 70-year-old patient who has had a recent cerebrovascular accident,the nurse notices right-sided weakness.What might the nurse expect to find when testing his reflexes on the right side?

Accepted Answer

A) Lack of reflexes 
B) Normal reflexes 
C) Diminished reflexes 
D) Hyperactive reflexes

Question 16

In obtaining a health history on a 74-year-old patient,the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things.With this information,what response should the nurse make?

Accepted Answer

A) "Does your family know you are drinking every day?" 
B) "Does the tremor change when you drink alcohol?" 
C) "We'll do some tests to see what is causing the tremor." 
D) "You really shouldn't drink so much alcohol; it may be causing your tremor."

Exam 23: Neurologic System