Introductory Medical Surgical Nursing 11th Edition by Barbara K. Tim
Introductory Medical Surgical Nursing 11th Edition by Barbara K. Tim
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Chapter 36, Introduction to the Nervous System
Complete Chapter Questions With Answers
Sample Questions Are Posted Below
| 1. | The family nurse practitioner is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly? | |
| A) | Moving the head toward both sides | |
| B) | Lightly tapping the lower portion of the neck to detect sensation | |
| C) | Moving the head and chin toward the chest | |
| D) | Gently pressing the bones on the neck | |
| Ans: | C | |
| Feedback: | ||
| The neck is examined for stiffness or abnormal position. The presence of rigidity is assessed by moving the head and chin toward the chest. The nurse should not maneuver the neck if a head or neck injury is suspected or known. The neck should also not be maneuvered if trauma to any part of the body is evident. Moving the head toward the sides or pressing the bones on the neck will not help assess for neck rigidity correctly. While assessing for neck rigidity, sensation at the neck area is not to be assessed. | ||
| 2. | The critical care nurse is giving report on a client she is caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? | |
| A) | Comatose | |
| B) | Somnolence | |
| C) | Stupor | |
| D) | Normal | |
| Ans: | A | |
| Feedback: | ||
| The GSC is used to measure the LOC. The scale consists of three parts: eye opening response, best verbal response, and best motor response. A normal response is 15. A score of 7 or less is considered comatose. Therefore, a score of 6 indicates the client is in a state of coma and not in any other state such as stupor or somnolence. The evaluations are recorded on a graphic sheet where connecting lines show an increase or decrease in the LOC. | ||
| 3. | The nurse is caring for a comatose client. The nurse knows she should assess the client’s motor response. Which method may the nurse use to assess the motor response? | |
| A) | Observing the reaction of pupils to light | |
| B) | Observing the client’s response to painful stimulus | |
| C) | Using the Romberg test | |
| D) | Assessing the client’s sensitivity to temperature, touch, and pain | |
| Ans: | B | |
| Feedback: | ||
| The nurse evaluates motor response in a comatose or unconscious client by administering a painful stimulus. This action helps determine if the client makes an appropriate response by reaching toward or withdrawing from the stimulus. The Romberg test is used to assess equilibrium in a noncomatose client. Pupils are examined for their reaction to light to assess sensitivity in the third cranial (oculomotor) nerve. Sensitivity to temperature, touch, and pain is a test to assess the sensory function of the client and not motor response. | ||
| 4. | A female client undergoes a scheduled electroencephalogram (EEG). Which of the following postprocedure activities should the nurse carry out for the client? | |
| A) | Allow the client to rest and shampoo the client’s hair. | |
| B) | Provide the client with adequate caffeine-rich drinks. | |
| C) | Measure the level of consciousness (LOC) of the client. | |
| D) | Measure the heart and the pulse rate. | |
| Ans: | A | |
| Feedback: | ||
| After an EEG, the nurse should ensure rest for the sleep-deprived client and shampoo the client’s hair to remove the glue used to affix electrodes to the scalp. The client is advised not to take sedative drugs and caffeine-related drinks before the EEG, and there is no reason to provide the client with them after the test. The nurse should not measure the LOC, the heart rate, or the pulse rate of the client unless advised by the physician. | ||
| 5. | The nurse is caring for a client who is undergoing single-photon emission computed tomography (SPECT). What is a potential side effect that this client may suffer? | |
| A) | Headache and pain in the neck | |
| B) | Claustrophobia | |
| C) | Allergic reaction to the imaging material | |
| D) | Allergic reaction to radioactive rays | |
| Ans: | C | |
| Feedback: | ||
| SPECT obtains images of the brain after the client intravenously receives radiopharmaceuticals and radioisotopes approximately 1 hour before the test begins. A potential risk of SPECT is the client’s allergic reaction to the imaging material. Headache is an aftereffect of a cisternal puncture, and claustrophobia may be experienced by clients during a magnetic resonance imaging scan. | ||
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