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Terms in this set (20)1. When admitting an acutely confused patient with a head injury, which action should the nurse take? a. Ask family members about the patient's health history. ANS: A When admitting a patient who is likely to be a poor historian, the nurse should obtain health history information from others who have knowledge about the patient's health. Waiting until the patient is oriented or obtaining only physiologic data will result in incomplete assessment data, which could adversely affect decision making about treatment. Asking leading questions may result in inaccurate or incomplete information. 2. Which finding should the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion? a. Spasticity ANS: B Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor neuron lesions. 3. What should the nurse include in a focused assessment of a patient's left posterior temporal lobe functions? a. Sensation on the left side of the body ANS: C The posterior temporal lobe integrates the visual and auditory input for language comprehension. Reasoning and problem solving are functions of the anterior frontal lobe. Sensation on the left side of the body is located in the right postcentral gyrus. Voluntary movement on the right side is controlled in the left precentral gyrus. 4. How should the nurse assess the patient's trigeminal and facial nerve function (CNs V and VII)? a. Check for
unilateral eyelid droop. ANS: C The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to evaluate function of the oculomotor nerve. 5. Which action should 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)? a. Assist to stand and ambulate. ANS: B The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. A patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve. Balance and coordination are cerebellar functions. 6. An unconscious male patient has just arrived in the emergency department with a head injury caused by a motorcycle crash. Which planned intervention by the health care provider should the nurse question? a. Obtain x-rays of the skull and spine. ANS: B After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure. Herniation of the brain could result if lumbar puncture is performed. The other orders are appropriate. 7. A patient with suspected meningitis is scheduled for a lumbar puncture. What action should the nurse take before the procedure? a. Enforce NPO status for 4 hours. ANS: D For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration. 8. 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. What should the nurse suspect as a likely cause of these findings? a. Cerebellar injury ANS: C Expressive speech (ability to express the self in language) is controlled by Broca's area in the frontal lobe. The temporal lobe contains Wernicke's area, which is responsible for receptive speech (ability to understand language input). The cerebellum and brainstem do not affect higher cognitive functions such as speech. 9. A patient has a tumor in the cerebellum. What goal should the nurse use to focus the plan of care? a. Prevent falls. ANS: A Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability. 10. Which problem should the nurse expect for a patient who has a positive Romberg test result? a. Pain ANS: B A positive Romberg test result indicates that the patient has difficulty maintaining balance when standing with the eyes closed. The Romberg test does not assess orientation, thermoregulation, or discomfort. 11. Which test should the nurse anticipate discussing with a patient who has a possible seizure disorder? a. Cerebral angiography ANS: D Seizure disorders are usually assessed using EEG testing. Evoked potential is used to diagnose problems with the visual or auditory systems. Cerebral angiography is used to diagnose vascular problems. EMG is used to evaluate electrical innervation to skeletal muscle.
12. Which equipment should the nurse obtain to assess vibration sense in a patient with diabetes who has peripheral nerve dysfunction? a. Sharp pin ANS: B Vibration sense is testing by touching the patient with a vibrating tuning fork. The other equipment is needed for testing of pain sensation, reflexes, and two-point discrimination. 13. Which information about a 76-yr-old patient should the nurse identify as uncharacteristic of normal aging? a. Triceps reflex response graded at 1/5 ANS: B Although changes in appetite are normal with aging, a 15-pound weight loss requires further investigation. Orthostatic drops in blood pressure, changes in sleep patterns, and slowing of reflexes are normal changes in aging. 14. The charge nurse is observing a new nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action by the new nurse indicates the need for further teaching about neurologic assessment? a. Tests for light touch before testing for pain. ANS: C When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate. 15. Which cerebrospinal fluid analysis result should the nurse recognize as abnormal and communicate to the health care provider? a. Specific
gravity of 1.007 ANS: B The protein level is high. The specific gravity, WBCs, and glucose values are normal. 16. 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? a. The patient is anxious about the test results. ANS: B A contrast medium containing iodine is injected into the subarachnoid space during a myelogram. The patient's allergy would contraindicate the use of this medium. The health care provider may need to provide orders to treat back pain after the procedure. Clear liquids are usually considered safe up to 4 hours before a diagnostic or surgical procedure. The patient's anxiety should be addressed, but procedural plans would not need to be changed. 17. Which of the following should the nurse consider the priority nursing assessment for a patient being admitted with a brainstem infarction? a. Pupil reaction ANS: B Vital centers that control respiration are located in the medulla and part of the brainstem. They require priority assessments because changes in respiratory function may be life threatening. The other information will also be obtained by the nurse but is not as urgent. 18. Several patients have been hospitalized for diagnosis of neurologic problems. Which patient should the nurse assess first? a. A patient with a transient ischemic attack (TIA) returning from carotid duplex studies ANS: B Because cerebral angiograms require insertion of a catheter into the femoral artery, bleeding is a possible complication. The nurse will need to check the pulse and blood pressure and assess the catheter insertion site in the groin as soon as the patient arrives. Carotid duplex studies and EEG are noninvasive. The nurse will need to assist with the lumbar puncture as soon as possible but monitoring for hemorrhage after cerebral angiogram has a higher priority MULTIPLE RESPONSE 1. Which assessments should the nurse make to monitor a patient's cerebellar function? (Select all that apply.) a. Test for graphesthesia. ANS: B, C The cerebellum is responsible for coordination and is assessed by looking at the patient's gait and the finger-to-nose test. The other assessments will be used for other parts of the neurologic assessment 2. Which nursing actions should be included in the plan of care for a patient after cerebral angiography? (Select all that apply.) a. Monitor for photophobia. ANS: B, D, E Because a catheter is inserted into an artery (e.g., the femoral artery) during cerebral angiography, the nurse should assess for bleeding at the site and bleeding that may affect pulse and blood pressure. Neuro status should be assessed often. There is no reason to keep the patient NPO. Photophobia is not expected. Sets found in the same folderch. 2523 terms nursemom09 Chapter 57 Stroke44 terms tlstill99 Powerpoint questions5 terms shaylyn_rowe Chapter 5632 terms Queen_meen Other sets by this creatorChapter 42: The Child With Cardiovascular Dysfunct…57 terms lsp2012 Chapter 42: Fluid, Electrolyte, and Acid-Base Bala…47 terms lsp2012 Concept 8 acid base balance7 terms lsp2012 Chapter 29 Fluids and Electrolytes15 terms lsp2012 Other Quizlet setsBannister/Purkey 2018Civil War28 terms Joshua_Bannister NR 442 - Exam 1, community health exam 1…350 terms chad_williams8 Management 301 Maxwell29 terms WCBaller24 MA 135 PHLEBOTOMY51 terms quizlette11862235PLUS |
Which test should the nurse anticipate discussing with a patient who has a possible seizure disorder?
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