MULTIPLE CHOICE
1. The nurse teaches an 80-year-old client with diminished peripheral sensation. Which
statement would 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 injuries from your shoes.‖
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 his or
her 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.
DIF: Applying TOP: Integrated Process: Teaching/Learning
KEY: Neurologic assessment, Changes associated with aging, Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
2. The nurse assesses a client‘s recent memory. Which statement by the client confirms that
recent 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.‖
ANS: D
Asking clients about recent events that can be verified, such as what the client ate for breakfast,
assesses recent memory. 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 immediate memory.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Neurologic assessment, Memory
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A client is admitted to the emergency department with a probable traumatic brain injury.
Which assessment finding would be the priority for the nurse to report to the primary health
care provider?
a. Mild temporal headache
b. Pupils equal and react to light
c. Alert and oriented 3
d. Decreasing level of consciousness
ANS: D
A decreasing level of consciousness is the first sign of increasing intracranial pressure, a potentially
severe and possibly fatal complication of a traumatic brain injury (TBI). A mild
, headache would be expected for a client having a TBI. Equal reactive pupils and being alert and
oriented are normal assessment findings.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Neurologic assessment, Level of consciousness
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4. A nurse asks a client to take deep breaths during an electroencephalography. The client asks,
―Why are you asking me to do this?‖ How would the nurse respond?
a. ―Hyperventilation causes vascular dilation of cerebral arteries, which decreases
electoral activity in the brain.‖
b. ―Deep breathing helps you to relax and allows the electroencephalograph to obtain
a better waveform.‖
c. ―Hyperventilation causes cerebral vasoconstriction and increases the likelihood of
seizure activity.‖
d. ―Deep breathing will help you to blow off carbon dioxide and decreases
intracranial pressures.‖
ANS: C
Hyperventilation produces cerebral vasoconstriction and alkalosis, which increase the likelihood
of seizure activity. The client is asked to breathe deeply 20 times for 3 minutes. The other
responses are not accurate.
DIF: Understanding TOP: Integrated Process: Teaching/Learning
KEY: Assessment, Diagnostic testing
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5. A nurse assesses a client recovering from a cerebral angiography via the right femoral artery.
Which assessment would the nurse complete?
a. Palpate bilateral lower extremity pulses.
b. Obtain orthostatic blood pressure readings.
c. Perform a funduscopic examination.
d. Assess the gag reflex prior to eating.
ANS: A
Cerebral angiography is performed by threading a catheter through the femoral or brachial artery. The
extremity is kept immobilized after the procedure. The nurse checks the extremity for adequate
circulation by noting skin color and temperature, presence and quality of pulses distal to the injection
site, and capillary refill. Clients usually are on bedrest; therefore, orthostatic blood pressure readings
cannot be performed. The funduscopic (eye) examination would not be affected by cerebral
angiography. The client is not given general anesthesia; therefore, the client‘s gag reflex would not be
compromised.
DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment
KEY: Assessment, Diagnostic testing
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6. When assessing a client who had a traumatic brain injury, the nurse notes that the client is
drowsy but easily aroused. What level of consciousness will the nurse document to describe
this client‘s current level of consciousness?
, a. Alert
b. Lethargic
c. Stuporous
d. Comatose
ANS: B
The client is categorized as being lethargic because he or she can be easily aroused even though
drowsy. The nurse would carefully monitor the client to determine any decrease in the level of
consciousness (LOC).
DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment
KEY: Neurologic assessment, Level of consciousness
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
7. The nurse is assessing a client diagnosed with trigeminal neuralgia affecting cranial nerve V.
What assessment findings will the nurse expect for this client?
a. Expressive aphasia
b. Ptosis (eyelid drooping)
c. Slurred speech
d. Severe facial pain
ANS: D
Cranial nerve (CN) V is the Trigeminal Nerve which has both a motor and sensory function in the face.
When affected by a health problem, the client experiences severely facial pain.
Expressive aphasia results from damage to the Broca speech area in the frontal lobe of the brain.
Ptosis can result from damage to CN III and slurred speech often occurs from either damage to several
cranial nerves or from damage to the motor strip in the frontal lobe of the brain.
DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment
KEY: Neurologic assessment, Cranial nerve assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
8. The nurse is performing an assessment of cranial nerve III. Which testing is appropriate?
a. Pupil constriction
b. Deep tendon reflexes
c. Upper muscle strength
d. Speech and language
ANS: A
CN III is the oculomotor nerve which controls eye movement, pupil constriction, and eyelid movement.
DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment
KEY: Neurologic assessment, Cranial nerve assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
9. A nurse cares for a client who is experiencing deteriorating neurologic functions. The client
states, ―I am worried I will not be able to care for my young children.‖ How would the nurse
respond?
a. ―Caring for your children is a priority. You may not want to ask for help, but you
, really have to.‖
b. ―Our community has resources that may help you with some household tasks so
you have energy to care for your children.‖
c. ―You seem distressed. Would you like to talk to a psychologist about adjusting to
your changing status?‖
d. ―Can you tell me more about what worries you, so we can see if we can do
something to make adjustments?‖
ANS: D
Investigate specific concerns about situational or role changes before providing additional
information. The nurse would not tell the client what is or is not a priority for him or her. Although
community resources may be available, they may not be appropriate for the patient. Consulting a
psychologist would not be appropriate without obtaining further information from the client related to
current concerns.
DIF: Applying TOP: Integrated Process: Communication and Documentation KEY:
Neurologic assessment, Therapeutic communication, Psychosocial assessment MSC:
Client Needs Category: Psychosocial Integrity
10. A nurse plans care for a 77-year-old client who is experiencing age-related
peripheral sensory perception changes. Which intervention would the nurse include in this client‘s plan
of care?
a. Provide a call button that requires only minimal pressure to activate.
b. Write the date on the client‘s white board to promote orientation.
c. Ensure that the path to the bathroom is free from clutter.
d. Encourage the client to season food to stimulate nutritional intake.
ANS: C
Dementia and confusion are not common phenomena in older adults. However, physical impairment
related to illness can be expected. Providing opportunities for hazard-free ambulation will maintain
strength and mobility (and ensure safety). Providing a call button, providing the date, and seasoning
food do not address the client‘s impaired sensory perception.
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: Neurologic assessment, Client safety, Changes associated with aging
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
11. After teaching a patient who is scheduled for magnetic resonance imaging (MRI), the nurse
assesses the client‘s understanding. Which statement indicates client understanding of the
teaching?
a. ―I must increase my fluids because of the dye used for the MRI.‖
b. ―My urine will be radioactive so I should not share a bathroom.‖
c. ―My gag reflex will be tested before I can eat or drink anything.‖
d. ―I can return to my usual activities immediately after the MRI.‖
ANS: D
No postprocedure restrictions are imposed after MRI. The client can return to normal activities after
the test is complete. There are no dyes or radioactive materials used for the MRI; therefore, increased
fluids are not needed and the client‘s urine would not be
1. The nurse teaches an 80-year-old client with diminished peripheral sensation. Which
statement would 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 injuries from your shoes.‖
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 his or
her 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.
DIF: Applying TOP: Integrated Process: Teaching/Learning
KEY: Neurologic assessment, Changes associated with aging, Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
2. The nurse assesses a client‘s recent memory. Which statement by the client confirms that
recent 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.‖
ANS: D
Asking clients about recent events that can be verified, such as what the client ate for breakfast,
assesses recent memory. 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 immediate memory.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Neurologic assessment, Memory
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A client is admitted to the emergency department with a probable traumatic brain injury.
Which assessment finding would be the priority for the nurse to report to the primary health
care provider?
a. Mild temporal headache
b. Pupils equal and react to light
c. Alert and oriented 3
d. Decreasing level of consciousness
ANS: D
A decreasing level of consciousness is the first sign of increasing intracranial pressure, a potentially
severe and possibly fatal complication of a traumatic brain injury (TBI). A mild
, headache would be expected for a client having a TBI. Equal reactive pupils and being alert and
oriented are normal assessment findings.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Neurologic assessment, Level of consciousness
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4. A nurse asks a client to take deep breaths during an electroencephalography. The client asks,
―Why are you asking me to do this?‖ How would the nurse respond?
a. ―Hyperventilation causes vascular dilation of cerebral arteries, which decreases
electoral activity in the brain.‖
b. ―Deep breathing helps you to relax and allows the electroencephalograph to obtain
a better waveform.‖
c. ―Hyperventilation causes cerebral vasoconstriction and increases the likelihood of
seizure activity.‖
d. ―Deep breathing will help you to blow off carbon dioxide and decreases
intracranial pressures.‖
ANS: C
Hyperventilation produces cerebral vasoconstriction and alkalosis, which increase the likelihood
of seizure activity. The client is asked to breathe deeply 20 times for 3 minutes. The other
responses are not accurate.
DIF: Understanding TOP: Integrated Process: Teaching/Learning
KEY: Assessment, Diagnostic testing
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5. A nurse assesses a client recovering from a cerebral angiography via the right femoral artery.
Which assessment would the nurse complete?
a. Palpate bilateral lower extremity pulses.
b. Obtain orthostatic blood pressure readings.
c. Perform a funduscopic examination.
d. Assess the gag reflex prior to eating.
ANS: A
Cerebral angiography is performed by threading a catheter through the femoral or brachial artery. The
extremity is kept immobilized after the procedure. The nurse checks the extremity for adequate
circulation by noting skin color and temperature, presence and quality of pulses distal to the injection
site, and capillary refill. Clients usually are on bedrest; therefore, orthostatic blood pressure readings
cannot be performed. The funduscopic (eye) examination would not be affected by cerebral
angiography. The client is not given general anesthesia; therefore, the client‘s gag reflex would not be
compromised.
DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment
KEY: Assessment, Diagnostic testing
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6. When assessing a client who had a traumatic brain injury, the nurse notes that the client is
drowsy but easily aroused. What level of consciousness will the nurse document to describe
this client‘s current level of consciousness?
, a. Alert
b. Lethargic
c. Stuporous
d. Comatose
ANS: B
The client is categorized as being lethargic because he or she can be easily aroused even though
drowsy. The nurse would carefully monitor the client to determine any decrease in the level of
consciousness (LOC).
DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment
KEY: Neurologic assessment, Level of consciousness
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
7. The nurse is assessing a client diagnosed with trigeminal neuralgia affecting cranial nerve V.
What assessment findings will the nurse expect for this client?
a. Expressive aphasia
b. Ptosis (eyelid drooping)
c. Slurred speech
d. Severe facial pain
ANS: D
Cranial nerve (CN) V is the Trigeminal Nerve which has both a motor and sensory function in the face.
When affected by a health problem, the client experiences severely facial pain.
Expressive aphasia results from damage to the Broca speech area in the frontal lobe of the brain.
Ptosis can result from damage to CN III and slurred speech often occurs from either damage to several
cranial nerves or from damage to the motor strip in the frontal lobe of the brain.
DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment
KEY: Neurologic assessment, Cranial nerve assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
8. The nurse is performing an assessment of cranial nerve III. Which testing is appropriate?
a. Pupil constriction
b. Deep tendon reflexes
c. Upper muscle strength
d. Speech and language
ANS: A
CN III is the oculomotor nerve which controls eye movement, pupil constriction, and eyelid movement.
DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment
KEY: Neurologic assessment, Cranial nerve assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
9. A nurse cares for a client who is experiencing deteriorating neurologic functions. The client
states, ―I am worried I will not be able to care for my young children.‖ How would the nurse
respond?
a. ―Caring for your children is a priority. You may not want to ask for help, but you
, really have to.‖
b. ―Our community has resources that may help you with some household tasks so
you have energy to care for your children.‖
c. ―You seem distressed. Would you like to talk to a psychologist about adjusting to
your changing status?‖
d. ―Can you tell me more about what worries you, so we can see if we can do
something to make adjustments?‖
ANS: D
Investigate specific concerns about situational or role changes before providing additional
information. The nurse would not tell the client what is or is not a priority for him or her. Although
community resources may be available, they may not be appropriate for the patient. Consulting a
psychologist would not be appropriate without obtaining further information from the client related to
current concerns.
DIF: Applying TOP: Integrated Process: Communication and Documentation KEY:
Neurologic assessment, Therapeutic communication, Psychosocial assessment MSC:
Client Needs Category: Psychosocial Integrity
10. A nurse plans care for a 77-year-old client who is experiencing age-related
peripheral sensory perception changes. Which intervention would the nurse include in this client‘s plan
of care?
a. Provide a call button that requires only minimal pressure to activate.
b. Write the date on the client‘s white board to promote orientation.
c. Ensure that the path to the bathroom is free from clutter.
d. Encourage the client to season food to stimulate nutritional intake.
ANS: C
Dementia and confusion are not common phenomena in older adults. However, physical impairment
related to illness can be expected. Providing opportunities for hazard-free ambulation will maintain
strength and mobility (and ensure safety). Providing a call button, providing the date, and seasoning
food do not address the client‘s impaired sensory perception.
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: Neurologic assessment, Client safety, Changes associated with aging
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
11. After teaching a patient who is scheduled for magnetic resonance imaging (MRI), the nurse
assesses the client‘s understanding. Which statement indicates client understanding of the
teaching?
a. ―I must increase my fluids because of the dye used for the MRI.‖
b. ―My urine will be radioactive so I should not share a bathroom.‖
c. ―My gag reflex will be tested before I can eat or drink anything.‖
d. ―I can return to my usual activities immediately after the MRI.‖
ANS: D
No postprocedure restrictions are imposed after MRI. The client can return to normal activities after
the test is complete. There are no dyes or radioactive materials used for the MRI; therefore, increased
fluids are not needed and the client‘s urine would not be
