Med Surg, Nervous System Study Questions

Med Surg, Nervous System Study Questions Study 1. When admitting an acutely confused patient with a head injury, which action should the nurse take? a. Ask family members about the patient's health history. b. Ask leading questions to assist in obtaining health data. c. Wait until the patient is bett er 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 patie nt's 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 i nformation. 2. Which finding would the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion? a. Spasticity c. Impaired sensation b. Flaccidity d. Hyperactive reflexes ANS: B Because the cell bodies of lower motor neurons ar e 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. reasoning and problem -solving ability. c. ability to understand written and oral language. d. voluntary movements on t he right side of the body. ANS: C 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. Vol untary 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. c. constipation. b. bradycardia. 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 periph eral nervous system blockade. 5. To assess the functions of the trigeminal and facial nerves (CNs V and VII), the nurse should a. check for unilateral eyelid droop. b. shine a light into the patient's pupil. c. touch a cotton wisp strand to the cornea. d. have the patient read a magazine or book. ANS: C 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. Asse ssment of pupil response to light and ptosis are used to evaluate 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 vagus nerv e (CN X)? a. Assist to stand and ambulate. c. Insert an oropharyngeal airway. b. Withhold oral fluids and food. d. Apply artificial tears every hour. ANS: B The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. A patient w ith 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. Balance and coordination are cerebellar functions. 7. An unconscious male patient has just arrived in the emergency department with 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, an d herniation of the brain could result if 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 l ateral 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 pati ent is unable to respond verbally to the nurse but cooperates with the nurse's directions to move his hands and feet. The nurse will suspect a. cerebellar injury. c. frontal lobe damage.