Chapter 43: Assessment of the Nervous System

Chapter 43: Assessment of the Nervous System

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. The nurse assesses a client who has trauma to the cerebrum. Which clinical manifestation does the nurse expect to observe?

a.	Poor coordination
b.	Memory loss
c.	Hyperthermia
d.	Slurred speech

 

 

ANS:  B

The cerebrum is the largest part of the brain and controls intelligence, creativity, and memory. Poor coordination, hyperthermia, and slurred speech are caused by other parts of the brain.

 

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Assessment)

 

2. The nurse is assessing a client with a frontal lobe brain injury. Which clinical manifestation does the nurse expect to see?

a.	Inability to interpret taste sensations
b.	Inability to interpret sound
c.	Impaired judgment
d.	Impaired learning

 

 

ANS:  C

The frontal lobe is responsible for many functions, including judgment, reasoning, voluntary eye movement, and motor functions. The other clinical manifestations are not associated with the frontal lobe.

 

DIF:    Cognitive Level: Knowledge/Remembering                       REF:   Table 43-1, p. 907

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Assessment)

 

3. The nurse is planning to provide discharge teaching related to cardiac medications to a client who has experienced damage to the left temporal lobe of the brain. What does the nurse do to assist the client to understand the content of the instruction?

a.	Use a larger print size for written materials.
b.	Ensure that the client is wearing glasses.
c.	Point out the color of the medication.
d.	Sit on the client’s right side.

 

 

ANS:  D

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 to the right ear. The other interventions do not address the client’s left temporal lobe damage.

 

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC:  Integrated Process: Teaching/Learning

 

4. After performing a physical assessment on a 75-year-old client, the nurse notes that the client has a hypoactive response to a test of deep tendon reflexes. Which intervention does the nurse include in this client’s plan of care?

a.	Assist the client with ambulation.
b.	Elevate the client’s lower extremities.
c.	Apply elastic support hose.
d.	Massage the client’s legs.

 

 

ANS:  A

The older adult experiences certain neurologic changes associated with aging. Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. The nurse or assistive personnel should assist this client with ambulation to prevent injury. The other interventions do not address the client’s problem.

 

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Aging Process)

MSC:  Integrated Process: Nursing Process (Implementation)