Chapter 55: Assessment of Nervous System

Chapter 55: Assessment of Nervous System

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

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.
b.	Ask leading questions to assist in obtaining health data.
c.	Wait until the patient is better oriented to ask questions.
d.	Obtain only the physiologic neurologic assessment data.

 

 

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.

 

DIF:    Cognitive Level: Apply (application)           REF:               1301

TOP:   Nursing Process: Assessment           MSC:  NCLEX: Physiological Integrity

 

2. Which finding would the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion?

a.	Spasticity	c.	Impaired sensation
b.	Flaccidity	d.	Hyperactive reflexes

 

 

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.

 

DIF:    Cognitive Level: Understand (comprehension)                   REF:   1296

TOP:   Nursing Process: Assessment           MSC:  NCLEX: Physiological Integrity

 

3. The nurse performing a focused assessment of left posterior temporal lobe functions will assess the patient for

a.	sensation on the left side of the body.
b.	reasoning and problem-solving ability.
c.	ability to understand written and oral language.
d.	voluntary movements on the right 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.

 

DIF:    Cognitive Level: Apply (application)           REF:               1298

TOP:   Nursing Process: Assessment           MSC:  NCLEX: Physiological Integrity

 

4. Propranolol (Inderal), a b-adrenergic blocker that inhibits sympathetic nervous system activity, is prescribed for a patient who has extreme anxiety about public speaking. The nurse monitors the patient for

a.	dry mouth.	c.	constipation.
b.	bradycardia.	d.	urinary retention.

 

 

ANS:  B

Inhibition of the fight-or-flight response leads to a decreased heart rate. Dry mouth, constipation, and urinary retention are associated with peripheral nervous system blockade.

 

DIF:    Cognitive Level: Understand (comprehension)                   REF:   1299

TOP:   Nursing Process: Evaluation            MSC:  NCLEX: Physiological Integrity

 

5. To assess the functions of the trigeminal and facial nerves (CNs V and VII), the nurse should

a.	check for unilateral eyelid droop.
b.	shine a light into the patient’s pupil.
c.	touch a cotton wisp strand to the cornea.
d.	have the patient read a magazine or book.

 

 

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.

 

DIF:    Cognitive Level: Understand (comprehension)                   REF:   1305

TOP:   Nursing Process: Assessment           MSC:  NCLEX: Physiological Integrity