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Neuro Test Bank Exam/158 complete Q’s and A’s
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Neuro Test Bank Exam/158 complete Q’s and A’s
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Neuro Test Bank Exam/158complete Q’s and A’s
When admitting an acutely confused 20-year-old patient with a head injury,
which action should the nurse take?
a. Ask family members about the patients 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. - -a. Ask family
members about the patients health history.
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 patients 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.
-Which finding would the nurse expect when assessing the legs of a patient
who has a lower motor neuron lesion?
a. Spasticity
b. Flaccidity
c. No sensation
d. Hyperactive reflexes - -b. Flaccidity
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.
-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. voluntary movements on the right side.
c. reasoning and problem-solving abilities.
d. understanding written and oral language. - -d. understanding written and
oral language.
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.
, -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.
b. bradycardia.
c. constipation.
d. urinary retention. - -b. bradycardia
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.
-To assess the functioning of the trigeminal and facial nerves (CNs V and
VII), the nurse should
a. shine a light into the patients pupil.
b. check for unilateral eyelid drooping.
c. touch a cotton wisp strand to the cornea.
d. have the patient read a magazine or book. - -a. shine a light into the
patients pupil.
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.
-Which action will the nurse include in the plan of care for a patient with
impaired functioning of the left glossopharyngeal nerve (CN IX) and the
vagus nerve (CN X)?
a. Withhold oral fluid or foods.
b. Provide highly seasoned foods.
c. Insert an oropharyngeal airway.
d. Apply artificial tears every hour. - -a. Withhold oral fluid or foods.
The glossopharyngeal and vagus nerves innervate the pharynx and control
the gag reflex. A patient with impaired function of these nerves is at risk for
aspiration. An oral airway may be needed when a patient is unconscious and
unable to maintain the airway, but it will not decrease aspiration risk. Taste
and eye blink are controlled by the facial nerve.
-An unconscious male patient has just arrived in the emergency department
after a head injury caused by a motorcycle crash. Which order should the
nurse question?
a. Obtain x-rays of the skull and spine.
b. Prepare the patient for lumbar puncture.
c. Send for computed tomography (CT) scan.
,d. Perform neurologic checks every 15 minutes. - -b. Prepare the patient for
lumbar puncture.
After a head injury, the patient may be experiencing intracranial bleeding
and increased intracranial pressure, which could lead to herniation of the
brain if a lumbar puncture is performed. The other orders are appropriate.
-A patient with suspected meningitis is scheduled for a lumbar puncture.
Before the procedure, the nurse will plan to
a. enforce NPO status for 4 hours.
b. transfer the patient to radiology.
c. administer a sedative medication.
d. help the patient to a lateral position. - -d. help the patient to a lateral
position.
For a lumbar puncture, the patient lies in the lateral recumbent position. The
procedure does not usually require a sedative, is done in the patient room,
and has no risk for aspiration.
-During the neurologic assessment, the patient is unable to respond verbally
to the nurse but cooperates with the nurses directions to move his hands
and feet. The nurse will suspect
a. cerebellar injury.
b. a brainstem lesion.
c. frontal lobe damage.
d. a temporal lobe lesion. - -c. frontal lobe damage.
Expressive speech is controlled by Brocas area in the frontal lobe. The
temporal lobe contains Wernickes area, which is responsible for receptive
speech. The cerebellum and brainstem do not affect higher cognitive
functions such as speech.
-A 45-year-old patient has a dysfunction of the cerebellum. The nurse will
plan interventions to
a. prevent falls.
b. stabilize mood.
c. avoid aspiration.
d. improve memory. - -a. prevent falls.
Because functions of the cerebellum include coordination and balance, the
patient with dysfunction is at risk for falls. The cerebellum does not affect
memory, mood, or swallowing ability.
DIF: Cognitive Level: Apply (application) REF: 1339-1340
-Which nursing diagnosis is expected to be appropriate for a patient who has
a positive Romberg test?
, a. Acute pain
b. Risk for falls
c. Acute confusion
d. Ineffective thermoregulation - -b. Risk for falls
A positive Romberg test indicates that the patient has difficulty maintaining
balance with the eyes closed. The Romberg does not test for orientation,
thermoregulation, or discomfort.
-The nurse will anticipate teaching a patient with a possible seizure disorder
about which test?
a. Cerebral angiography
b. Evoked potential studies
c. Electromyography (EMG)
d. Electroencephalography (EEG) - -d. Electroencephalography (EEG)
Seizure disorders are usually assessed using EEG testing. Evoked potential is
used for diagnosing problems with the visual or auditory systems. Cerebral
angiography is used to diagnose vascular problems. EMG is used to evaluate
electrical innervation to skeletal muscle.
-Which nursing action will be included in the care for a patient who has had
cerebral angiography?
a. Monitor for headache and photophobia.
b. Keep patient NPO until gag reflex returns.
c. Check pulse and blood pressure frequently.
d. Assess orientation to person, place, and time. - -c. Check pulse and blood
pressure frequently.
Because a catheter is inserted into an artery (such as the femoral artery)
during cerebral angiography, the nurse should assess for bleeding after this
procedure. The other nursing assessments are not necessary after
angiography.
-Which equipment will the nurse obtain to assess vibration sense in a
diabetic patient who has peripheral nerve dysfunction?
a. Sharp pin
b. Tuning fork
c. Reflex hammer
d. Calibrated compass - -b. Tuning fork
Vibration sense is testing by touching the patient with a vibrating tuning
fork. The other equipment is needed for testing of pain sensation, reflexes,
and two-point discrimination.
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