Chapter 38: Assessment of the
Nervous System Ignatavicius:
Medical-Surgical Nursing, Updated
Edition
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." - 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 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.
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." - Answer 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.
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
, 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.
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? - Answer 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."
Part 2 # 4 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 - Answer
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. - Answer 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,
Nervous System Ignatavicius:
Medical-Surgical Nursing, Updated
Edition
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." - 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 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.
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." - Answer 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.
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
, 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.
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? - Answer 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."
Part 2 # 4 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 - Answer
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. - Answer 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,
