Question 1

Which finding would the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion?

Accepted Answer

A)  Spasticity
B)  Flaccidity
C)  Impaired sensation
D)  Hyperactive reflexes B

Question 2

Which information about a 76-yr-old patient should the nurse report as uncharacteristic of normal aging?

Accepted Answer

A)  Triceps reflex response graded at 1/5
B)  Unintended weight loss of 15 pounds
C)  10 mm Hg orthostatic drop in systolic blood pressure
D)  Patient complaint of chronic difficulty in falling asleep B

Question 3

Which problem can the nurse expect for a patient who has a positive Romberg test result?

Accepted Answer

A)  Pain
B)  Falls
C)  Aphasia
D)  Confusion B

Question 4

An unconscious male patient has just arrived in the emergency department with a head injury caused by a motorcycle crash. Which order should the nurse question?

Accepted Answer

A)  Obtain x-rays of the skull and spine.
B)  Prepare the patient for lumbar puncture.
C)  Send for computed tomography (CT)  scan.
D)  Perform neurologic checks every 15 minutes.

Question 5

During the neurologic assessment,the patient is unable to respond verbally to the nurse but cooperates with the nurse's directions to move his hands and feet. The nurse will suspect

Accepted Answer

A)  cerebellar injury.
B)  a brainstem lesion.
C)  frontal lobe damage.
D)  a temporal lobe lesion.

Question 6

The priority nursing assessment for a patient being admitted with a brainstem infarction is

Accepted Answer

A)  pupil reaction.
B)  respiratory rate.
C)  reflex reaction time.
D)  level of consciousness.

Question 7

To assess the functions of the trigeminal and facial nerves (CNs V and VII),the nurse should

Accepted Answer

A)  check for unilateral eyelid droop.
B)  shine a light into the patient's pupil.
C)  touch a cotton wisp strand to the cornea.
D)  have the patient read a magazine or book.

Question 8

Which cerebrospinal fluid analysis result should the nurse recognize as abnormal and communicate to the health care provider?

Accepted Answer

A)  Specific gravity of 1.007
B)  Protein of 65 mg/dL (0.65 g/L) 
C)  Glucose of 45 mg/dL (1.7 mmol/L) 
D)  White blood cell (WB
C)   count of 4 cells/mL

Question 9

A 39-yr-old patient with a suspected herniated intervertebral disc is scheduled for a myelogram. Which information communicated by the nurse to the health care provider before the procedure would change the procedural plans?

Accepted Answer

A)  The patient is anxious about the test results.
B)  The patient reports a previous allergy to shellfish.
C)  The patient has back pain when lying flat for more than 4 hours.
D)  The patient drank apple juice 4 hours before the scheduled procedure.

Question 10

The charge nurse is observing a new staff nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action indicates a need for further teaching of the new nurse about neurologic assessment?

Accepted Answer

A)  The new nurse tests for light touch before testing for pain.
B)  The new nurse has the patient close the eyes during testing.
C)  The new nurse asks the patient if the instrument feels sharp.
D)  The new nurse uses an irregular pattern to test for intact touch.

Question 11

When admitting an acutely confused patient with a head injury,which action should the nurse take?

Accepted Answer

A)  Ask family members about the patient's health history.
B)  Ask leading questions to assist in obtaining health data.
C)  Wait until the patient is better oriented to ask questions.
D)  Obtain only the physiologic neurologic assessment data.

Question 12

Which equipment will the nurse obtain to assess vibration sense in a patient with diabetes who has peripheral nerve dysfunction?

Accepted Answer

A)  Sharp pin
B)  Tuning fork
C)  Reflex hammer
D)  Calibrated compass

Question 13

Several patients have been hospitalized for diagnosis of neurologic problems. Which patient will the nurse assess first?

Accepted Answer

A)  A patient with a transient ischemic attack (TI
A)   returning from carotid duplex studies
B)  A patient with a brain tumor who has just arrived on the unit after a cerebral angiogram
C)  A patient with a seizure disorder who has just completed an electroencephalogram (EEG) 
D)  A patient prepared for a lumbar puncture whose health care provider is waiting for assistance

Question 14

A patient has a tumor in the cerebellum. The nurse will plan interventions to

Accepted Answer

A)  prevent falls.
B)  stabilize mood.
C)  avoid aspiration.
D)  improve memory.

Question 15

The nurse will anticipate teaching a patient with a possible seizure disorder about which test?

Accepted Answer

A)  Cerebral angiography
B)  Evoked potential studies
C)  Electromyography (EMG) 
D)  Electroencephalography (EEG)

Question 16

Which assessments will the nurse make to monitor a patient's cerebellar function ?

Accepted Answer

A)  Test for graphesthesia.
B)  Observe arm swing with gait.
C)  Perform the finger-to-nose test.
D)  Assess heat and cold sensation.
E)  Measure strength against resistance.

Question 17

A patient with suspected meningitis is scheduled for a lumbar puncture. Before the procedure,the nurse will plan to

Accepted Answer

A)  enforce NPO status for 4 hours.
B)  transfer the patient to radiology.
C)  administer a sedative medication.
D)  help the patient to a lateral position.

Question 18

Which nursing action will be included in the plan of care for a patient who has had cerebral angiography?

Accepted Answer

A)  Monitor for headache and photophobia.
B)  Keep patient NPO until gag reflex returns.
C)  Check pulse and blood pressure frequently.
D)  Assess orientation to person, place, and time.

Question 19

Propranolol (Inderal),a b-adrenergic blocker that inhibits sympathetic nervous system activity,is prescribed for a patient who has extreme anxiety about public speaking. The nurse monitors the patient for

Accepted Answer

A)  dry mouth.
B)  bradycardia.
C)  constipation.
D)  urinary retention.

Question 20

Which action will the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX)and vagus nerve (CN X)?

Accepted Answer

A)  Assist to stand and ambulate.
B)  Withhold oral fluids and food.
C)  Insert an oropharyngeal airway.
D)  Apply artificial tears every hour.

Exam 55: Assessment of Nervous System