Med SURG, Nervous System Study
Questions
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 better oriented to ask questions.
d.
Obtain only the physiologic neurologic assessment data. - Answer-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 patient'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 information.
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 - Answer-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.
reasoning and problem-solving ability.
c.
ability to understand written and oral language.
d.
voluntary movements on the right side of the body. - Answer-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. 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.
c.
constipation.
b.
bradycardia.
d.
urinary retention. - Answer-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 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. - Answer-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. Assessment 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 nerve (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. - Answer-ANS: B
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. 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. - Answer-ANS: B
After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial
pressure, and 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.
Questions
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 better oriented to ask questions.
d.
Obtain only the physiologic neurologic assessment data. - Answer-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 patient'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 information.
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 - Answer-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.
reasoning and problem-solving ability.
c.
ability to understand written and oral language.
d.
voluntary movements on the right side of the body. - Answer-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. 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.
c.
constipation.
b.
bradycardia.
d.
urinary retention. - Answer-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 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. - Answer-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. Assessment 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 nerve (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. - Answer-ANS: B
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. 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. - Answer-ANS: B
After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial
pressure, and 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.
