Chapter 41: Assessment of the Nervous System med/surg
A nurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which action should the nurse take when providing education about newly prescribed medications to this client? a. Help the client identify each medication by its color. b. Provide written materials with large print size. c. Sit on the client's right side and speak into the right ear. d. Allow the client to use a white board to ask questions. Correct answer- ANS: C The temporal lobe contains the auditory center for sound interpretation. The client's hearing will be impaired in the left ear. The nurse should sit on the client's right side and
speak into the right ear. The other interventions do not address the client's left temporal lobe damage.
DIF: Applying/Application REF: 831 KEY: Patient education| brain trauma/injury/tumor MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Psychosocial Integrity
A nurse plans care for a client who has a hypoactive response to a test of deep tendon reflexes. Which intervention should the nurse include in this client's plan of care? a. Check bath water temperature with a thermometer. b. Provide the client with assistance when ambulating. c. Place elastic support hose on the client's legs. d. Assess the client's feet for wounds each shift. Correct answer- ANS: B Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. The nurse should plan to provide the client with ambulation assistance to prevent injury. The other interventions do not address the client's problem.
DIF: Applying/Application REF: 838 KEY: Patient safety| motor/sensory impairment MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
A nurse teaches an 80-year-old client with diminished touch sensation. Which statement
should the nurse include in this client's teaching? a. "Place soft rugs in your bathroom to decrease pain in your feet."
b. "Bathe in warm water to increase your circulation."
c. "Look at the placement of your feet when walking." d. "Walk barefoot to decrease pressure ulcers from your shoes." Correct answer- ANS: C Older clients with decreased sensation are at risk of injury from the inability to sense changes in terrain when walking. To compensate for this loss, the client is instructed to look at the placement of her or his feet when walking. Throw rugs can slip and increase fall risk. Bath water that is too warm places the client at risk for thermal injury. The client
should wear sturdy shoes for ambulation.
DIF: Applying/Application REF: 836 KEY: Patient safety| motor/sensory impairment MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
A nurse assesses a client's recent memory. Which client statement confirms that the client's remote memory is intact? a. "A young girl wrapped in a shroud fell asleep on a bed of clouds."
b. "I was born on April 3, 1967, in Johnstown Community Hospital."
c. "Apple, chair, and pencil are the words you just stated."
d. "I ate oatmeal with wheat toast and orange juice for breakfast." Correct answer- ANS: D Asking clients about recent events that can be verified, such as what the client ate for breakfast, assesses the client's recent memory. The client's ability to make up a rhyme tests not memory, but rather a higher level of cognition. Asking clients about certain facts from the past that can be verified assesses remote or long-term memory. Asking the client to repeat words assesses the client's immediate memory.
DIF: Applying/Application REF: 839 KEY: Memory| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Health Promotion and Maintenance
A nurse assesses a client who demonstrates a positive Romberg's sign with eyes closed but not with eyes open. Which condition does the nurse associate with this finding? a. Difficulty with proprioception b. Peripheral motor disorder c. Impaired cerebellar function d. Positive pronator drift Correct answer- ANS: A The client who sways with eyes closed (positive Romberg's sign) but not with eyes open most likely has a disorder of proprioception and uses vision to compensate for it. The other options do not describe a positive Romberg's sign.
DIF: Applying/Application REF: 842 KEY: Motor/sensory impairment
A nurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which action should the nurse take when providing education about newly prescribed medications to this client? a. Help the client identify each medication by its color. b. Provide written materials with large print size. c. Sit on the client's right side and speak into the right ear. d. Allow the client to use a white board to ask questions. Correct answer- ANS: C The temporal lobe contains the auditory center for sound interpretation. The client's hearing will be impaired in the left ear. The nurse should sit on the client's right side and
speak into the right ear. The other interventions do not address the client's left temporal lobe damage.
DIF: Applying/Application REF: 831 KEY: Patient education| brain trauma/injury/tumor MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Psychosocial Integrity
A nurse plans care for a client who has a hypoactive response to a test of deep tendon reflexes. Which intervention should the nurse include in this client's plan of care? a. Check bath water temperature with a thermometer. b. Provide the client with assistance when ambulating. c. Place elastic support hose on the client's legs. d. Assess the client's feet for wounds each shift. Correct answer- ANS: B Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. The nurse should plan to provide the client with ambulation assistance to prevent injury. The other interventions do not address the client's problem.
DIF: Applying/Application REF: 838 KEY: Patient safety| motor/sensory impairment MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
A nurse teaches an 80-year-old client with diminished touch sensation. Which statement
should the nurse include in this client's teaching? a. "Place soft rugs in your bathroom to decrease pain in your feet."
b. "Bathe in warm water to increase your circulation."
c. "Look at the placement of your feet when walking." d. "Walk barefoot to decrease pressure ulcers from your shoes." Correct answer- ANS: C Older clients with decreased sensation are at risk of injury from the inability to sense changes in terrain when walking. To compensate for this loss, the client is instructed to look at the placement of her or his feet when walking. Throw rugs can slip and increase fall risk. Bath water that is too warm places the client at risk for thermal injury. The client
should wear sturdy shoes for ambulation.
DIF: Applying/Application REF: 836 KEY: Patient safety| motor/sensory impairment MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
A nurse assesses a client's recent memory. Which client statement confirms that the client's remote memory is intact? a. "A young girl wrapped in a shroud fell asleep on a bed of clouds."
b. "I was born on April 3, 1967, in Johnstown Community Hospital."
c. "Apple, chair, and pencil are the words you just stated."
d. "I ate oatmeal with wheat toast and orange juice for breakfast." Correct answer- ANS: D Asking clients about recent events that can be verified, such as what the client ate for breakfast, assesses the client's recent memory. The client's ability to make up a rhyme tests not memory, but rather a higher level of cognition. Asking clients about certain facts from the past that can be verified assesses remote or long-term memory. Asking the client to repeat words assesses the client's immediate memory.
DIF: Applying/Application REF: 839 KEY: Memory| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Health Promotion and Maintenance
A nurse assesses a client who demonstrates a positive Romberg's sign with eyes closed but not with eyes open. Which condition does the nurse associate with this finding? a. Difficulty with proprioception b. Peripheral motor disorder c. Impaired cerebellar function d. Positive pronator drift Correct answer- ANS: A The client who sways with eyes closed (positive Romberg's sign) but not with eyes open most likely has a disorder of proprioception and uses vision to compensate for it. The other options do not describe a positive Romberg's sign.
DIF: Applying/Application REF: 842 KEY: Motor/sensory impairment
