Test Bank NSG 210 Introduction to the Nervous System Questions & Answers & Rationale,100% CORRECT
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NSG 210
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NSG 210
Test Bank NSG 210 Introduction to the Nervous System Questions & Answers & Rationale
1. The family nurse practitioner is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity...
test bank nsg 210 introduction to the nervous system questions amp answers amp rationale
1 the family nurse practitioner is performing the physical examination of a client with a suspected neurol
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Test Bank NSG 210 Introduction to the Nervous System
Questions & Answers & Rationale
1. The family nurse practitioner is performing the physical examination
of a client with a suspected neurologic disorder. In addition to assessing
other parts of the body, the nurse should assess for neck rigidity. Which
method should help the nurse assess for neck rigidity correctly?
A) Moving the head toward both sides
B) Lightly tapping the lower portion of the neck to detect sensation
C) Moving the head and chin toward the chest
D) Gently pressing the bones on the neck
Ans: C
Feedback:
The neck is examined for stiffness or abnormal position. The presence of
rigidity is assessed by moving the head and chin toward the chest. The nurse
should not maneuver the neck if a head or neck injury is suspected or known.
The neck should also not be maneuvered if trauma to any part of the body is
evident. Moving the head toward the sides or pressing the bones on the neck
will not help assess for neck rigidity correctly. While assessing for neck
rigidity, sensation at the neck area is not to be assessed.
2. The critical care nurse is giving report on a client she is caring for. The
nurse uses the Glasgow Coma Scale (GCS) to assess the level of
consciousness (LOC) of a female client and reports to the oncoming nurse
that the client has an LOC of 6. What does an LOC score of 6 in a client
indicate?
A) Comatose
B) Somnolence
C) Stupor
D) Normal
Ans: A
Feedback:
The GSC is used to measure the LOC. The scale consists of three parts: eye
opening response, best verbal response, and best motor response. A normal
response is 15. A score of 7 or less is considered comatose. Therefore, a score
of 6 indicates the client is in a state of coma and not in any other state such as
stupor or somnolence. The evaluations are recorded on a graphic sheet where
connecting lines show an increase or decrease in the LOC.
Page 1
, 3. The nurse is caring for a comatose client. The nurse knows she should
assess the client's motor response. Which method may the nurse use to
assess the motor response?
A) Observing the reaction of pupils to light
B) Observing the client's response to painful stimulus
C) Using the Romberg test
D) Assessing the client's sensitivity to temperature, touch,
and pain Ans: B
Feedback:
The nurse evaluates motor response in a comatose or unconscious client by
administering a painful stimulus. This action helps determine if the client
makes an appropriate
Page 2
, response by reaching toward or withdrawing from the stimulus. The
Romberg test is used to assess equilibrium in a noncomatose client. Pupils
are examined for their reaction to light to assess sensitivity in the third
cranial (oculomotor) nerve. Sensitivity to temperature, touch, and pain is a
test to assess the sensory function of the client and not motor response.
4.A female client undergoes a scheduled electroencephalogram (EEG). Which
of the following postprocedure activities should the nurse carry out for the
client?
A) Allow the client to rest and shampoo the client's hair.
B) Provide the client with adequate caffeine-rich drinks.
C) Measure the level of consciousness (LOC) of the client.
D) Measure the heart and the pulse rate.
Ans: A
Feedback:
After an EEG, the nurse should ensure rest for the sleep-deprived client and
shampoo the client's hair to remove the glue used to affix electrodes to the
scalp. The client is advised not to take sedative drugs and caffeine-related
drinks before the EEG, and there is no reason to provide the client with
them after the test. The nurse should not measure the LOC, the heart rate, or
the pulse rate of the client unless advised by the physician.
5.The nurse is caring for a client who is undergoing single-photon emission
computed tomography (SPECT). What is a potential side effect that this client
may suffer?
A) Headache and pain in the neck
B) Claustrophobia
C) Allergic reaction to the imaging material
D) Allergic reaction to radioactive rays
Ans: C
Feedback:
SPECT obtains images of the brain after the client intravenously receives
radiopharmaceuticals and radioisotopes approximately 1 hour before the test
begins. A potential risk of SPECT is the client's allergic reaction to the
imaging material. Headache is an aftereffect of a cisternal puncture, and
claustrophobia may be experienced by clients during a magnetic resonance
imaging scan.
Page 3
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