1. 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.
ANS: A
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.
2. 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
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.
3. 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
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.
4. Propranolol
(Inderal), a -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
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.
5. 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
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.
6. 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
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.
7. 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
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.
8. 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
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.
9. 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
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.
10. 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
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.
11. 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
ANS: B
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.
12. 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)
ANS: D
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.
13. 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.
ANS: C
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.
Category | ATI |
Release date | 2021-09-14 |
Pages | 10 |
Language | English |
Comments | 0 |
Sales | 0 |
{{ userMessage }}