Chapter 56: Nursing Assessment: Nervous System

Chapter 56: Nursing Assessment: 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; this could adversely affect decision-making about treatment.
Asking leading questions may result in inaccurate or incomplete information.
DIF: Cognitive Level: Application REF: 1412-1413
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. A patient has a lesion that affects lower motor neurons. During assessment of the
patient’s lower extremities, the nurse expects to find
a. spasticity.
b. flaccidity.
c. loss of sensation.
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: Comprehension REF: 1408-1409
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3. When performing a focused assessment on a patient with a lesion of the left posterior
temporal lobe, the nurse will assess for
a. sensation on the left side of the body.
b. voluntary movement on the right side.
c. reasoning and problem-solving abilities.
d. understanding of written and oral language.
Test Bank 56-2
ANS: D
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: Application REF: 1409
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
4. Propranolol (Inderal), a β-adrenergic blocker that inhibits sympathetic nervous system
activity, is prescribed for a patient. The nurse monitors the patient for
a. dry mouth.
b. constipation.
c. slowed pulse.
d. urinary retention.
ANS: C
Inhibition of the fight or flight response leads to decreased heart rate. Dry mouth,
constipation, and urinary retention are associated with peripheral nervous system
blockade.
DIF: Cognitive Level: Comprehension REF: 1407 TOP: Nursing Process:
Evaluation
MSC: NCLEX: Physiological Integrity
5. To assess the functioning of the trigeminal and facial nerves (CN V and VII), the nurse
should
a. apply a cotton wisp strand to the cornea.
b. have the patient read a magazine or book.
c. shine a bright light into the patient’s pupil.
d. check for unilateral drooping of the eyelids.
ANS: A
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 check function of the oculomotor nerve.
DIF: Cognitive Level: Comprehension REF: 1416-1417
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity