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Assessment of The Nervous System Chapter 38 Exam With Complete Solutions
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Assessment of The Nervous System Chapter 38 ExamWith Complete Solutions
1. The nurse is teaching a client who is 80 years old and has diminished peripheral
sensation. Which of the following statements would the nurse include in this client's
teaching?
a. "Place soft rugs in your bathroom to decrease pain in your feet."
b. "Bathe in warm water to increase your circulation."
c. "Look at the placement of your feet when walking."
d. "Walk barefoot to decrease pressure injuries from your shoes." ANSWER ANS: C
Older, sensation-impaired clients are at risk for injury from inability to detect changes in
terrain during ambulation. The client is instructed to watch the position of his or her feet
during walking as a compensatory mechanism. Throw rugs can slip and increase fall
risk. Bath water that is too warm places the client in danger of thermal injury.
2. A nurse is testing a client's remote memory. Which of the following statements by the
client would identify the presence of remote memory?
a. "A little girl dressed up in a white mask slept on a bed of white feathers."
b. "I was born on April 3, 1967, in Johnstown Community Hospital."
c. "Apple, chair, and pencil are the words you just mentioned."
d. "I had oatmeal with wheat toast and orange juice for breakfast." - ANSWER ANS: D
Recent memory is assessed by asking the client about recent events that can be
verified, for example, what the client ate for breakfast. Remote or long-term memory is
assessed by asking the client to identify specific facts from the past that can be verified.
Immediate memory is assessed by asking the client to repeat words.
3. A client is brought to the emergency department with a possible traumatic brain
injury. Which of the following findings during the nurse's assessment would require
notification of the primary health care provider?
a. Mild temporal headache
, b. Pupils equal and react to light
c. Alert and oriented 3
d. Decreasing level of consciousness - ANSWER ANS: D
A decreasing level of consciousness is the first sign of this potentially serious and
possibly fatal complication, increasing intracranial pressure, of a traumatic brain injury.
For a client with a TBI, the nurse would expect some symptoms to include a mild
headache. The normal assessment findings include equal reactive pupils and being alert
and oriented.
4. A nurse is providing care for a client who is receiving an electroencephalography and
requests that the client hyperventilate. The client asks, "Why are you asking me to do
this?" Which is the nurse's best response?
a. "Hyperventilation causes vascular dilation of cerebral arteries, which decreases
electoral activity in the brain."
b. "Deep breathing helps you to relax and allows the electroencephalograph to obtain
a better waveform."
c. "Hyperventilation causes cerebral vasoconstriction and increases the likelihood of
seizure activity."
d. "Deep breathing will help you to blow off carbon dioxide and decreases
intracranial pressures." - ANSWER ANS: C
Hyperventilation produces cerebral vasoconstriction and alkalosis, which increase the
risk for seizure activity. The client is instructed to breathe deeply 20 times for 3 minutes.
The other responses are incorrect.
5. A nurse assesses a client who is receiving care following a cerebral angiography via
the right femoral artery. What would the nurse assess?
a. Auscultate bilateral lower extremity pulses.
b. Take orthostatic blood pressure measurements.
c. Conduct a funduscopic examination.
d. Check the gag reflex prior to feeding. - ANSWER ANS: A
Cerebral angiography is performed by advancing a catheter through the femoral or
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