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Neuro Test Bank
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Neuro Test BankWhen 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. - ANS 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 - ANS 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. - ANS 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. - ANS 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. - ANS 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. - ANS 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. - ANS 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. - ANS 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. - ANS 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. - ANS 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.
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