Chapter 55: Assessment of Nervous System Lewis: Medical-Surgical Nursing, 10th Edition

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. 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. DIF: Cognitive Level: Apply (application) REF: 1301 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 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 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. DIF: Cognitive Level: Understand (comprehension) REF: 1296 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 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. 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