C HAPTER 17: T HE N ERVOUS S YSTEM
MULTIPLE CHOICE
1. When taking the health history on a patient with a seizure disorder, the
nurse assesses whether the patient has an aura. Which of these would be
the best question for obtaining this information?
a. Does your muscle tone seem tense or limp?
b. After the seizure, do you spend a lot of time sleeping?
c. Do you have any warning sign before your seizure starts?
d. Do you experience any color change or incontinence during the
seizure?
ANS: C
Aura is a subjecti ve sensation that precedes a seizure; it could be
auditory, visual, or motor. The other questions do not solicit
information about an aura.
DIF: Cognitive Level: Appl ying (Application) REF: p. 641 MSC:
Client Needs: Physiologic Integrit y: Physiologic Ada ptation
2. While obtaining a health history of a 3 -month-old infant from the mother,
the nurse asks about the infants abilit y to suck and grasp the mothers
finger. What is the nurse assessing?
a. Reflexes
b. Intelligence
c. CNs
, d. Cerebral cortex function
ANS: A
Questions regarding reflexes include such questions as, What have you
noticed about the infants behavior, Are the infants sucking and
swallowing seem coordinated, and Does the infant grasp your finger?
The other responses are incorrect.
DIF: Cognitive Leve l: Understanding (Comprehension) REF: p. 642
MSC: Client Needs: Health Promotion and Maintenance
3. In obtaining a health history on a 74 -year -old patient, the nurse notes that
he drinks alcohol daily and that he has noticed a tremor in his hands that
affects his abilit y to hold things. With this information, what response
should the nurse make?
a. Does your famil y know you are drinking every day?
b. Does the tremor change when you drink alcohol?
c. Well do some tests to see what is causing the tremor.
d. You reall y shouldn’t drink so much alcohol; it may be causing your
tremor.
ANS: B
Senile tremor is relieved by alcohol, although not a recommended
treatment. The nurse should assess whether the person is abusing
alcohol in an effort to relieve the tremor.
, DIF: Cognitive Level: Anal yzing (Anal ysis) REF: p. 643
MSC: Client Needs: Health Promotion and Maintenance
4. A 50-year-old woman is in the clinic for weakness in her left arm and leg
that she has noticed for the past week. The nurse should perform which
type of neurologic examination?
a. Glasgow Coma Scale
b. Neurologic recheck examination
c. Screening neurologic examination
d. Complete neurologic examination
ANS: D
The nurse should perform a complete neurologic examination on an
individual who has neurologic concerns (e.g., headache, weakness, loss
of coordination) or who is showing signs of neurologic dysfunction.
The Glasgow Coma Scale is used to define a persons level of
consciousness. The neurologic recheck examination is appropriate for
those who are demonstrating neurologic deficits. The screening
neurologic examination is performed on seemingl y well individuals
who have no significant subjective findings from the health history.
DIF: Cognitive Level: Appl ying (Application) REF: p. 644 MSC:
Client Needs: Health Promotion and Maintenance
5. During an assessment of the CNs, the nurse finds the following:
as ymmetry when the patient smiles or frowns, uneven lifting of the
eyebrows, sagging of the lower eyelids, and escape of air when the nurse
presses against the right puffed cheek. This would indicate dysfunction of
which of these CNs?
MULTIPLE CHOICE
1. When taking the health history on a patient with a seizure disorder, the
nurse assesses whether the patient has an aura. Which of these would be
the best question for obtaining this information?
a. Does your muscle tone seem tense or limp?
b. After the seizure, do you spend a lot of time sleeping?
c. Do you have any warning sign before your seizure starts?
d. Do you experience any color change or incontinence during the
seizure?
ANS: C
Aura is a subjecti ve sensation that precedes a seizure; it could be
auditory, visual, or motor. The other questions do not solicit
information about an aura.
DIF: Cognitive Level: Appl ying (Application) REF: p. 641 MSC:
Client Needs: Physiologic Integrit y: Physiologic Ada ptation
2. While obtaining a health history of a 3 -month-old infant from the mother,
the nurse asks about the infants abilit y to suck and grasp the mothers
finger. What is the nurse assessing?
a. Reflexes
b. Intelligence
c. CNs
, d. Cerebral cortex function
ANS: A
Questions regarding reflexes include such questions as, What have you
noticed about the infants behavior, Are the infants sucking and
swallowing seem coordinated, and Does the infant grasp your finger?
The other responses are incorrect.
DIF: Cognitive Leve l: Understanding (Comprehension) REF: p. 642
MSC: Client Needs: Health Promotion and Maintenance
3. In obtaining a health history on a 74 -year -old patient, the nurse notes that
he drinks alcohol daily and that he has noticed a tremor in his hands that
affects his abilit y to hold things. With this information, what response
should the nurse make?
a. Does your famil y know you are drinking every day?
b. Does the tremor change when you drink alcohol?
c. Well do some tests to see what is causing the tremor.
d. You reall y shouldn’t drink so much alcohol; it may be causing your
tremor.
ANS: B
Senile tremor is relieved by alcohol, although not a recommended
treatment. The nurse should assess whether the person is abusing
alcohol in an effort to relieve the tremor.
, DIF: Cognitive Level: Anal yzing (Anal ysis) REF: p. 643
MSC: Client Needs: Health Promotion and Maintenance
4. A 50-year-old woman is in the clinic for weakness in her left arm and leg
that she has noticed for the past week. The nurse should perform which
type of neurologic examination?
a. Glasgow Coma Scale
b. Neurologic recheck examination
c. Screening neurologic examination
d. Complete neurologic examination
ANS: D
The nurse should perform a complete neurologic examination on an
individual who has neurologic concerns (e.g., headache, weakness, loss
of coordination) or who is showing signs of neurologic dysfunction.
The Glasgow Coma Scale is used to define a persons level of
consciousness. The neurologic recheck examination is appropriate for
those who are demonstrating neurologic deficits. The screening
neurologic examination is performed on seemingl y well individuals
who have no significant subjective findings from the health history.
DIF: Cognitive Level: Appl ying (Application) REF: p. 644 MSC:
Client Needs: Health Promotion and Maintenance
5. During an assessment of the CNs, the nurse finds the following:
as ymmetry when the patient smiles or frowns, uneven lifting of the
eyebrows, sagging of the lower eyelids, and escape of air when the nurse
presses against the right puffed cheek. This would indicate dysfunction of
which of these CNs?
