Chapter 55: Assessment of Nervous
System Lewis: Medical-Surgical
Nursing, 10th Edition
A 39-12 months-vintage affected person with a suspected herniated intervertebral disc is
scheduled for a
myelogram. Which information communicated by the nurse to the health care issuer before
the process could exchange the procedural plans?
A. The patient is worrying about the check results.
B. The patient reports a previous hypersensitivity to shellfish.
C. The affected person has returned pain when mendacity flat for greater than 4 hours.
D. The patient drank apple juice four hours earlier than the scheduled manner. - ANS-ANS: B
A evaluation medium containing iodine is injected into the subarachnoid area at some point of a
myelogram. The affected person's hypersensitivity would contraindicate the use of this medium.
The fitness
care company may also want to modify the orders to prevent back pain, but this may be
achieved after
the procedure. Clear beverages are commonly taken into consideration safe as much as four
hours before a diagnostic or
surgical procedure. The patient's anxiety have to be addressed, but procedural plans might not
need to be modified.
DIF: Cognitive Level: Apply (software) REF: 1310
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A patient has a tumor within the cerebellum. The nurse will plan interventions to
a. Save you falls. C. Keep away from aspiration.
B. Stabilize mood. D. Improve memory. - ANS-ANS: A
Because functions of the cerebellum include coordination and balance, the patient with
disorder is at threat for falls. The cerebellum does not affect memory, temper, or swallowing
capability.
DIF: Cognitive Level: Apply (software) REF: 1298
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
A affected person with suspected meningitis is scheduled for a lumbar puncture. Before the
technique,
the nurse will plan to
a. Put into effect NPO reputation for 4 hours.
B. Transfer the patient to radiology.
C. Administer a sedative medicine.
, D. Help the patient to a lateral function. - ANS-ANS: D
For a lumbar puncture, the affected person lies in the lateral recumbent position. The manner
does
now not normally require a sedative, is finished within the affected person room, and has no
chance for aspiration.
DIF: Cognitive Level: Apply (software) REF: 1310
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
An unconscious male affected person has simply arrived inside the emergency department with
a head damage
resulting from a motorcycle crash. Which order should the nurse question?
A. Obtain x-rays of the cranium and spine.
B. Prepare the patient for lumbar puncture.
C. Send for computed tomography (CT) scan.
D. Perform neurologic exams each 15 mins. - ANS-ANS: B
After a head injury, the patient may be experiencing intracranial bleeding and improved
intracranial strain, and herniation of the mind should result if lumbar puncture is completed.
The other orders are appropriate.
DIF: Cognitive Level: Apply (application) REF: 1310
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
During the neurologic evaluation, the patient is unable to reply verbally to the nurse however
cooperates with the nurse's instructions to move his hands and ft. The nurse will suspect
a. Cerebellar injury. C. Frontal lobe harm.
B. A brainstem lesion. D. A temporal lobe lesion. - ANS-ANS: C
Expressive speech (capacity to explicit the self in language) is controlled via Broca's vicinity
inside the
frontal lobe. The temporal lobe carries Wernicke's vicinity, which is liable for receptive
speech (ability to understand language enter). The cerebellum and brainstem do not have an
effect on
higher cognitive features which includes speech.
DIF: Cognitive Level: Apply (application) REF: 1296
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
Propranolol (Inderal), a b-adrenergic blocker that inhibits sympathetic anxious machine
activity, is prescribed for a patient who has severe anxiety about public speakme. The nurse
monitors the patient for
a. Dry mouth. C. Constipation.
B. Bradycardia. D. Urinary retention. - ANS-ANS: B
Inhibition of the combat-or-flight reaction leads to a reduced coronary heart fee. Dry mouth,
constipation, and urinary retention are related to peripheral fearful system blockade.
DIF: Cognitive Level: Understand (comprehension) REF: 1299
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
Several patients were hospitalized for analysis of neurologic problems. Which patient
will the nurse verify first?
A. A patient with a transient ischemic assault (TIA) returning from carotid duplex
System Lewis: Medical-Surgical
Nursing, 10th Edition
A 39-12 months-vintage affected person with a suspected herniated intervertebral disc is
scheduled for a
myelogram. Which information communicated by the nurse to the health care issuer before
the process could exchange the procedural plans?
A. The patient is worrying about the check results.
B. The patient reports a previous hypersensitivity to shellfish.
C. The affected person has returned pain when mendacity flat for greater than 4 hours.
D. The patient drank apple juice four hours earlier than the scheduled manner. - ANS-ANS: B
A evaluation medium containing iodine is injected into the subarachnoid area at some point of a
myelogram. The affected person's hypersensitivity would contraindicate the use of this medium.
The fitness
care company may also want to modify the orders to prevent back pain, but this may be
achieved after
the procedure. Clear beverages are commonly taken into consideration safe as much as four
hours before a diagnostic or
surgical procedure. The patient's anxiety have to be addressed, but procedural plans might not
need to be modified.
DIF: Cognitive Level: Apply (software) REF: 1310
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A patient has a tumor within the cerebellum. The nurse will plan interventions to
a. Save you falls. C. Keep away from aspiration.
B. Stabilize mood. D. Improve memory. - ANS-ANS: A
Because functions of the cerebellum include coordination and balance, the patient with
disorder is at threat for falls. The cerebellum does not affect memory, temper, or swallowing
capability.
DIF: Cognitive Level: Apply (software) REF: 1298
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
A affected person with suspected meningitis is scheduled for a lumbar puncture. Before the
technique,
the nurse will plan to
a. Put into effect NPO reputation for 4 hours.
B. Transfer the patient to radiology.
C. Administer a sedative medicine.
, D. Help the patient to a lateral function. - ANS-ANS: D
For a lumbar puncture, the affected person lies in the lateral recumbent position. The manner
does
now not normally require a sedative, is finished within the affected person room, and has no
chance for aspiration.
DIF: Cognitive Level: Apply (software) REF: 1310
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
An unconscious male affected person has simply arrived inside the emergency department with
a head damage
resulting from a motorcycle crash. Which order should the nurse question?
A. Obtain x-rays of the cranium and spine.
B. Prepare the patient for lumbar puncture.
C. Send for computed tomography (CT) scan.
D. Perform neurologic exams each 15 mins. - ANS-ANS: B
After a head injury, the patient may be experiencing intracranial bleeding and improved
intracranial strain, and herniation of the mind should result if lumbar puncture is completed.
The other orders are appropriate.
DIF: Cognitive Level: Apply (application) REF: 1310
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
During the neurologic evaluation, the patient is unable to reply verbally to the nurse however
cooperates with the nurse's instructions to move his hands and ft. The nurse will suspect
a. Cerebellar injury. C. Frontal lobe harm.
B. A brainstem lesion. D. A temporal lobe lesion. - ANS-ANS: C
Expressive speech (capacity to explicit the self in language) is controlled via Broca's vicinity
inside the
frontal lobe. The temporal lobe carries Wernicke's vicinity, which is liable for receptive
speech (ability to understand language enter). The cerebellum and brainstem do not have an
effect on
higher cognitive features which includes speech.
DIF: Cognitive Level: Apply (application) REF: 1296
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
Propranolol (Inderal), a b-adrenergic blocker that inhibits sympathetic anxious machine
activity, is prescribed for a patient who has severe anxiety about public speakme. The nurse
monitors the patient for
a. Dry mouth. C. Constipation.
B. Bradycardia. D. Urinary retention. - ANS-ANS: B
Inhibition of the combat-or-flight reaction leads to a reduced coronary heart fee. Dry mouth,
constipation, and urinary retention are related to peripheral fearful system blockade.
DIF: Cognitive Level: Understand (comprehension) REF: 1299
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
Several patients were hospitalized for analysis of neurologic problems. Which patient
will the nurse verify first?
A. A patient with a transient ischemic assault (TIA) returning from carotid duplex
