Chapter 38: Assessment of the Nervous
System
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. 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
radioactive. The procedure does not impact the client’s gag reflex.
DIF: Understanding TOP: Integrated Process: Teaching/Learning
KEY: Neurologic assessment, Diagnostic testing, Client education
MSC: Client Needs Category: Physiological Integrity: Reduction of
Risk Potential
2. A nurse performs an assessment of pain discrimination on an older adult. The client
correctly identifies, with eyes closed, a sharp sensation on the right hand when
touched with a pin. Which action would the nurse take next?
, a. Touch the pin on the same area of the left hand.
b. Contact the primary health care provider with the assessment results.
c. Ask the client about current and past medications.
d. Continue the assessment on the client’s feet and legs.
ANS: A
If testing is begun on the right hand and the client correctly identifies the pain
stimulus, the nurse would continue the assessment on the left hand. This is a normal
finding and does not need to be reported to the provider, but instead documented in
the client’s medical record. Medications do not need to be assessed in response to this
finding. The nurse would assess the left hand prior to assessing the feet.
DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment
KEY: Neurologic assessment, Motor, Sensory impairment
MSC: Client Needs Category: Physiological Integrity: Physiological
Adaptation
3. A nurse is teaching a client with cerebellar function impairment. Which statement
would the nurse include in this client’s discharge teaching?
a. “Connect a light to flash when your door bell rings.”
b. “Label your faucet knobs with hot and cold signs.”
c. “Ask a friend to drive you to your follow-up appointments.”
d. “Use a natural gas detector with an audible alarm.”
ANS: C
Cerebellar function enables the client to predict distance or gauge the speed with
which one is approaching an object, control voluntary movement, maintain
equilibrium, and shift from one skilled movement to another in an orderly sequence.
A client who has cerebellar function impairment should not be driving. The client
would not have difficulty hearing, distinguishing between hot and cold, or smelling.
System
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. 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
radioactive. The procedure does not impact the client’s gag reflex.
DIF: Understanding TOP: Integrated Process: Teaching/Learning
KEY: Neurologic assessment, Diagnostic testing, Client education
MSC: Client Needs Category: Physiological Integrity: Reduction of
Risk Potential
2. A nurse performs an assessment of pain discrimination on an older adult. The client
correctly identifies, with eyes closed, a sharp sensation on the right hand when
touched with a pin. Which action would the nurse take next?
, a. Touch the pin on the same area of the left hand.
b. Contact the primary health care provider with the assessment results.
c. Ask the client about current and past medications.
d. Continue the assessment on the client’s feet and legs.
ANS: A
If testing is begun on the right hand and the client correctly identifies the pain
stimulus, the nurse would continue the assessment on the left hand. This is a normal
finding and does not need to be reported to the provider, but instead documented in
the client’s medical record. Medications do not need to be assessed in response to this
finding. The nurse would assess the left hand prior to assessing the feet.
DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment
KEY: Neurologic assessment, Motor, Sensory impairment
MSC: Client Needs Category: Physiological Integrity: Physiological
Adaptation
3. A nurse is teaching a client with cerebellar function impairment. Which statement
would the nurse include in this client’s discharge teaching?
a. “Connect a light to flash when your door bell rings.”
b. “Label your faucet knobs with hot and cold signs.”
c. “Ask a friend to drive you to your follow-up appointments.”
d. “Use a natural gas detector with an audible alarm.”
ANS: C
Cerebellar function enables the client to predict distance or gauge the speed with
which one is approaching an object, control voluntary movement, maintain
equilibrium, and shift from one skilled movement to another in an orderly sequence.
A client who has cerebellar function impairment should not be driving. The client
would not have difficulty hearing, distinguishing between hot and cold, or smelling.
