ATI Assessment of the Nervous System, Questions and Answers with Explanations.

ATI Assessment of the Nervous System, Questions and Answers with Explanations, 100% Correct, Download to Score A

Test Bank

MULTIPLE CHOICE

1. The nurse assesses a client who has trauma to the cerebrum. Which clinical manifestation does the nurse expect to observe?

a.	Poor coordination
b.	Memory loss
c.	Hyperthermia
d.	Slurred speech

ANS: B

The cerebrum is the largest part of the brain and controls intelligence, creativity, and memory. Poor coordination, hyperthermia, and slurred speech are caused by other parts of the brain.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

2. The nurse is assessing a client with a frontal lobe brain injury. Which clinical manifestation does the nurse expect to see?

a.	Inability to interpret taste sensations
b.	Inability to interpret sound
c.	Impaired judgment
d.	Impaired learning

ANS: C

The frontal lobe is responsible for many functions, including judgment, reasoning, voluntary eye movement, and motor functions. The other clinical manifestations are not associated with the frontal lobe.

DIF: Cognitive Level: Knowledge/Remembering REF: Table 43-1, p. 907

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

3. The nurse is planning to provide discharge teaching related to cardiac medications to a client who has experienced damage to the left temporal lobe of the brain. What does the nurse do to assist the client to understand the content of the instruction?

a.	Use a larger print size for written materials.
b.	Ensure that the client is wearing glasses.
c.	Point out the color of the medication.
d.	Sit on the client’s right side.

ANS: D

The temporal lobe contains the auditory center for sound interpretation. The client’s hearing will be impaired in the left ear. The nurse should sit on the client’s right side and speak to the right ear. The other interventions do not address the client’s left temporal lobe damage.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC: Integrated Process: Teaching/Learning

4. After performing a physical assessment on a 75-year-old client, the nurse notes that the client has a hypoactive response to a test of deep tendon reflexes. Which intervention does the nurse include in this client’s plan of care?

a.	Assist the client with ambulation.
b.	Elevate the client’s lower extremities.
c.	Apply elastic support hose.
d.	Massage the client’s legs.

ANS: A

The older adult experiences certain neurologic changes associated with aging. Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. The nurse or assistive personnel should assist this client with ambulation to prevent injury. The other interventions do not address the client’s problem.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process)

MSC: Integrated Process: Nursing Process (Implementation)

5. The nurse is discharging an 80-year-old client with diminished touch sensation. Which instruction does the nurse provide to promote client safety?

a.	“Walk barefoot only in your home.”
b.	“Bathe in warm water to increase your circulation.”
c.	“Look at the placement of your feet when walking.”
d.	“Put throw rugs at the foot of your bed for cushioning.”

ANS: C

Older clients with decreased sensation are at risk of injury from the inability to sense changes in terrain when walking. To compensate for this loss, the client is instructed to look at the placement of her or his feet when walking. The client also should wear sturdy shoes for ambulation. Throw rugs can slip and increase fall risk. Bath water that is too warm places the client at risk for thermal injury.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)

MSC: Integrated Process: Teaching/Learning

6. A client admitted the previous day for a suspected neurologic disorder becomes increasingly lethargic. Which is the best nursing action?

a.	Promote a quiet atmosphere for sleep and rest to treat the client’s sleep deprivation.
b.	Explain to the family that this is a normal age-related decline in mental processing.
c.	Consult a psychiatrist to treat the client’s hospital-acquired depression.
d.	Complete a full neurologic assessment and notify the neurologist.

ANS: D

A change in the client’s level of consciousness (LOC) is the first indication of a decline in central neurologic functioning. The nurse should conduct a thorough assessment and then should notify the neurologist (or other provider). The other interventions are inappropriate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

7. The nurse is assessing a client’s remote memory. Which statement by the client confirms that remote memory is intact?

a.	“Mary had a little lamb whose fleece was white as snow.”
b.	“I was born on April 3, 1967, in Johnstown Community Hospital.”
c.	“Apple, chair, and pencil are the words you just stated.”
d.	“My sister brought me to the clinic for this appointment.”

ANS: B

Asking clients about certain facts from the past that can be verified assesses remote, or long-term, memory. The client’s ability to make up a rhyme tests not memory, but

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