Priorities in Critical Care Nursing, 6th Edition by Linda D.
Priorities in Critical Care Nursing, 6th Edition by Linda D.
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Chapter 17: Neurological Clinical Assessment and Diagnostic Procedures
Complete Chapter Questions With Answers
Sample Questions Are Posted Below
MULTIPLE CHOICE
| a. | depth of inspiration. |
| b. | rhythm of respiration. |
| c. | length of inspiration and expiration |
| d. | depth of expiration. |
ANS: C
The apneustic and pneumotaxic centers of the pons are responsible for the length of inspiration and expiration and the underlying respiratory rate.
DIF: Cognitive Level: Comprehension REF: Table 17-2
OBJ: Nursing Process: Assessment TOP: Neurological Clinical Assessment
MSC: NCLEX: Client Need: Physiological Integrity: Reduction of Risk Potential
| a. | The patient reaches with the left hand to stop nail bed pressure on the right index finger. |
| b. | The patient attempts to withdraw the left foot as it is being subjected to pressure on the left great toe. |
| c. | The patient has no response to pressure from a sternal rub. |
| d. | The patient has spontaneous extension responses to pressure on the right index finger. |
ANS: A
Localization of motor function occurs when the extremity opposite the one receiving pain crosses the midline of the body in an attempt to remove the noxious stimulus from the affected limb.
DIF: Cognitive Level: Application REF: Box 17-4
OBJ: Nursing Process: Assessment TOP: Neurological Clinical Assessment
MSC: NCLEX: Client Need: Physiological Integrity: Reduction of Risk Potential
| a. | above the midbrain, in the region of the thalamus or cerebral hemispheres. |
| b. | in the sympathetic pathways of the brainstem. |
| c. | in the vestibular system. |
| d. | in the cerebellum. |
ANS: A
Decortication is manifested by an abnormal flexion response that may occur spontaneously or in response to noxious stimuli. Abnormal flexion occurs with lesions above the midbrain, in the region of the thalamus or cerebral hemispheres.
DIF: Cognitive Level: Comprehension REF: 344
OBJ: Nursing Process: Assessment TOP: Neurological Clinical Assessment
MSC: NCLEX: Client Need: Physiological Integrity: Reduction of Risk Potential
| a. | flaccid |
| b. | decorticate |
| c. | decerebrate |
| d. | localized |
ANS: A
Flaccidity is manifested by lack of response to painful stimuli.
DIF: Cognitive Level: Application REF: Box 17-4
OBJ: Nursing Process: Assessment TOP: Neurological Clinical Assessment
MSC: NCLEX: Client Need: Physiological Integrity: Reduction of Risk Potential
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