Chapter 41: Assessment of the Nervous System

Chapter 41: Assessment of the Nervous System

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. A nurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which action should the nurse take when providing education about newly prescribed medications to this client?
   1. Help the client identify each medication by its color.
   2. Provide written materials with large print size.
   3. Sit on the client’s right side and speak into the right ear.
   4. Allow the client to use a white board to ask questions.

ANS:   C

The temporal lobe contains the auditory center for sound interpretation. The client’s hearing will be impaired in the left ear. The nurse should sit on the client’s right side and speak into the right ear. The other interventions do not address the client’s left temporal lobe damage.

DIF:     Applying/Application                         REF: 831

KEY:   Patient education| brain trauma/injury/tumor

MSC:   Integrated Process: Teaching/Learning

NOT:   Client Needs Category: Psychosocial Integrity

2. A nurse plans care for a client who has a hypoactive response to a test of deep tendon reflexes. Which intervention should the nurse include in this client’s plan of care?
   1. Check bath water temperature with a thermometer.
   2. Provide the client with assistance when ambulating.
   3. Place elastic support hose on the client’s legs.
   4. Assess the client’s feet for wounds each shift.

ANS:   B

Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. The nurse should plan to provide the client with ambulation assistance to prevent injury. The other interventions do not address the client’s problem.

DIF:     Applying/Application                         REF: 838                     KEY: Patient safety| motor/sensory impairment                              MSC:                         Integrated Process: Nursing Process: Implementation                                 NOT:                          Client Needs Category: Physiological Integrity: Basic Care and Comfort

3. A nurse teaches an 80-year-old client with diminished touch sensation. Which statement should the nurse include in this client’s teaching?
   1. “Place soft rugs in your bathroom to decrease pain in your feet.”
   2. “Bathe in warm water to increase your circulation.”
   3. “Look at the placement of your feet when walking.”
   4. “Walk barefoot to decrease pressure ulcers from your shoes.”

ANS:   C

Older clients with decreased sensation are at risk of injury from the inability to sense changes in terrain when walking. To compensate for this loss, the client is instructed to look at the placement of her or his feet when walking. Throw rugs can slip and increase fall risk. Bath water that is too warm places the client at risk for thermal injury. The client should wear sturdy shoes for ambulation.

DIF:            Applying/Application                         REF:    836                   KEY: Patient safety| motor/sensory impairment                                                 MSC:             Integrated Process: Teaching/Learning                                                             NOT:              Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

4. A nurse assesses a client’s recent memory. Which client statement confirms that the client’s remote memory is intact?
   1. “A young girl wrapped in a shroud fell asleep on a bed of clouds.”
   2. “I was born on April 3, 1967, in Johnstown Community Hospital.”
   3. “Apple, chair, and pencil are the words you just stated.”
   4. “I ate oatmeal with wheat toast and orange juice for breakfast.”

ANS:           D

Asking clients about recent events that can be verified, such as what the client ate for breakfast, assesses the client’s recent memory. The client’s ability to make up a rhyme tests not memory, but rather a higher level of cognition. Asking clients about certain facts from the past that can be verified assesses remote or long-term memory. Asking the client to repeat words assesses the client’s immediate memory.

DIF:     Applying/Application             REF:    839       KEY: Memory| assessment/diagnostic examination              MSC: Integrated Process: Nursing Process: Assessment      NOT: Client Needs Category: Health Promotion and Maintenance