Nursing 406 Unit 3 Nclex
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1. Start: Chapter 65: Assessment of Neurologic Function: Start: Chapter 65: Assessment of
Neurologic Function
2. A patient is brought to the ER following a motor vehicle accident in which he
sustained head trauma. Preliminary assessment reveals a vision deficit in the
patients left eye. The nurse should associate this abnormal finding with trauma
to which of the following cerebral lobes?
A) Temporal
B) Occipital
C) Parietal
D) Frontal: Ans: B
Feedback: The posterior lobe of the cerebral hemisphere is responsible for visual interpretation. The temporal lobe
contains the auditory receptive areas. The parietal lobe contains the primary sensory cortex, and is essential to an
individuals awareness of the body in space, as well as orientation in space and spatial relations. The frontal lobe
functions in concentration, abstract thought, information storage or memory, and motor function.
3. A patient scheduled for magnetic resonance imaging (MRI) has arrived at the
radiology department. The nurse who prepares the patient for the MRI should
prioritize which of the following actions?
A) Withholding stimulants 24 to 48 hours prior to exam
B) Removing all metal-containing objects
C) Instructing the patient to void prior to the MRI
D) Initiating an IV line for administration of contrast: Ans: B
Feedback: Patient preparation for an MRI consists of removing all metal-containing objects prior to the examination.
Withholding stimulants would not affect an MRI; this relates to an electroencephalography (EEG). Instructing the patient
to void is patient preparation for a lumbar puncture. Initiating an IV line for administration of contrast would be done
if the patient was having a CT scan with contrast.
4. A gerontologic nurse planning the neurologic assessment of an older adult
is considering normal, agerelated changes. Of what phenomenon should the
nurse be aware?
A) Hyperactive deep tendon reflexes
, Nursing 406 Unit 3 Nclex
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B) Reduction in cerebral blood flow
C) Increased cerebral metabolism
D) Hypersensitivity to painful stimuli: Ans: B
Feedback: Reduction in cerebral blood flow (CBF) is a change that occurs in the normal aging process. Deep tendon
reflexes can be decreased or, in some cases, absent. Cerebral metabolism decreases as the patient advances in age.
Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be
used when hot or cold packs are used
5. The nurse has admitted a new patient to the unit. One of the patients
admitting orders is for an adrenergic medication. The nurse knows that this
medication will have what effect on the circulatory system?
A) Thin, watery saliva
B) Increased heart rate
C) Decreased BP
D) Constricted bronchioles: Ans: B
Feedback: The term adrenergic refers to the sympathetic nervous system. Sympathetic effects include an increased rate
and force of the heartbeat. Cholinergic effects, which correspond to the parasympathetic division of the autonomic
nervous system, include thin, watery saliva, decreased rate and force of heartbeat, and decreased BP.
6. A nurse is assessing reflexes in a patient with hyperactive reflexes. When the
patients foot is abruptly dorsiflexed, it continues to beat two to three times
before settling into a resting position. How would the nurse document this
finding?
A) Rigidity
B) Flaccidity
C) Clonus
D) Ataxia: Ans: C
Feedback: When reflexes are very hyperactive, a phenomenon called clonus may be elicited. If the foot is abruptly
dorsiflexed, it may continue to beat two to three times before it settles into a position of rest. Rigidity is an increase in
muscle tone at rest characterized by increased resistance to passive stretch. Flaccidity is lack of muscle tone. Ataxia is
the inability to coordinate muscle movements, resulting in difficulty walking, talking, and performing self-care activities.
, Nursing 406 Unit 3 Nclex
Study online at https://quizlet.com/_hmbu7a
7. The nurse is doing an initial assessment on a patient newly admitted to
the unit with a diagnosis of cerebrovascular accident (CVA). The patient has
difficulty copying a figure that the nurse has drawn and is diagnosed with
visual-receptive aphasia. What brain region is primarily involved in this deficit?
A) Temporal lobe
B) Parietal-occipital area
C) Inferior posterior frontal areas
D) Posterior frontal area: Ans: B
Feedback: Difficulty copying a figure that the nurse has drawn would be considered visual-receptive aphasia, which
involves the parietal-occipital area. Expressive aphasia, the inability to express oneself, is often associated with damage
to the frontal area. Receptive aphasia, the inability to understand what someone else is saying, is often associated with
damage to the temporal lobe area.
8. What term is used to describe the fibrous connective tissue that hugs the
brain closely and extends into every fold of the brains surface?
A) Dura mater
B) Arachnoid
C) Fascia
D) Pia mater: Ans: D
Feedback: The term meninges describes the fibrous connective tissue that covers the brain and spinal cord. The
meninges have three layers, the dura mater, arachnoid, and pia mater. The pia mater is the innermost membrane that
hugs the brain closely and extends into every fold of the brains surface. The dura mater, the outermost layer, covers the
brain and spinal cord. The arachnoid, the middle membrane, is responsible for the production of cerebrospinal fluid.
9. The nurse is caring for a patient with an upper motor neuron lesion. What
clinical manifestations should the nurse anticipate when planning the patients
neurologic assessment?
A) Decreased muscle tone
B) Flaccid paralysis
C) Loss of voluntary control of movement
D) Slow reflexes: Ans: C
, Nursing 406 Unit 3 Nclex
Study online at https://quizlet.com/_hmbu7a
Feedback: Upper motor neuron lesions do not cause muscle atrophy, flaccid paralysis, or slow reflexes. However, upper
motor neuron lesions normally cause loss of voluntary control.
10. The nurse is admitting a patient to the unit who is diagnosed with a lower
motor neuron lesion. What entry in the patients electronic record is most
consistent with this diagnosis?
A) Patient exhibits increased muscle tone.
B) Patient demonstrates normal muscle structure with no evidence of atrophy.
C) Patient demonstrates hyperactive deep tendon reflexes.
D) Patient demonstrates an absence of deep tendon reflexes.: Ans: D
Feedback: Lower motor neuron lesions cause flaccid muscle paralysis, muscle atrophy, decreased muscle tone, and loss
of voluntary control
11. An elderly patient is being discharged home. The patient lives alone and has
atrophy of his olfactory organs. The nurse tells the patients family that it is
essential that the patient have what installed in the home?
A) Grab bars
B) Nonslip mats
C) Baseboard heaters
D) A smoke detector: Ans: D
Feedback: The sense of smell deteriorates with age. The olfactory organs are responsible for smell. This may present
a safety hazard for the patient because he or she may not smell smoke or gas leaks. Smoke detectors are universally
necessary, but especially for this patient.
12. The patient in the ED has just had a diagnostic lumbar puncture. To reduce
the incidence of a postlumbar puncture headache, what is the nurses most
appropriate action?
A) Position the patient prone.
B) Position the patient supine with the head of bed flat.
C) Position the patient left side-lying.
D) Administer acetaminophen as ordered: Ans: A
Feedback: The lumbar puncture headache may be avoided if a small-gauge needle is used and if the patient remains
Study online at https://quizlet.com/_hmbu7a
1. Start: Chapter 65: Assessment of Neurologic Function: Start: Chapter 65: Assessment of
Neurologic Function
2. A patient is brought to the ER following a motor vehicle accident in which he
sustained head trauma. Preliminary assessment reveals a vision deficit in the
patients left eye. The nurse should associate this abnormal finding with trauma
to which of the following cerebral lobes?
A) Temporal
B) Occipital
C) Parietal
D) Frontal: Ans: B
Feedback: The posterior lobe of the cerebral hemisphere is responsible for visual interpretation. The temporal lobe
contains the auditory receptive areas. The parietal lobe contains the primary sensory cortex, and is essential to an
individuals awareness of the body in space, as well as orientation in space and spatial relations. The frontal lobe
functions in concentration, abstract thought, information storage or memory, and motor function.
3. A patient scheduled for magnetic resonance imaging (MRI) has arrived at the
radiology department. The nurse who prepares the patient for the MRI should
prioritize which of the following actions?
A) Withholding stimulants 24 to 48 hours prior to exam
B) Removing all metal-containing objects
C) Instructing the patient to void prior to the MRI
D) Initiating an IV line for administration of contrast: Ans: B
Feedback: Patient preparation for an MRI consists of removing all metal-containing objects prior to the examination.
Withholding stimulants would not affect an MRI; this relates to an electroencephalography (EEG). Instructing the patient
to void is patient preparation for a lumbar puncture. Initiating an IV line for administration of contrast would be done
if the patient was having a CT scan with contrast.
4. A gerontologic nurse planning the neurologic assessment of an older adult
is considering normal, agerelated changes. Of what phenomenon should the
nurse be aware?
A) Hyperactive deep tendon reflexes
, Nursing 406 Unit 3 Nclex
Study online at https://quizlet.com/_hmbu7a
B) Reduction in cerebral blood flow
C) Increased cerebral metabolism
D) Hypersensitivity to painful stimuli: Ans: B
Feedback: Reduction in cerebral blood flow (CBF) is a change that occurs in the normal aging process. Deep tendon
reflexes can be decreased or, in some cases, absent. Cerebral metabolism decreases as the patient advances in age.
Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be
used when hot or cold packs are used
5. The nurse has admitted a new patient to the unit. One of the patients
admitting orders is for an adrenergic medication. The nurse knows that this
medication will have what effect on the circulatory system?
A) Thin, watery saliva
B) Increased heart rate
C) Decreased BP
D) Constricted bronchioles: Ans: B
Feedback: The term adrenergic refers to the sympathetic nervous system. Sympathetic effects include an increased rate
and force of the heartbeat. Cholinergic effects, which correspond to the parasympathetic division of the autonomic
nervous system, include thin, watery saliva, decreased rate and force of heartbeat, and decreased BP.
6. A nurse is assessing reflexes in a patient with hyperactive reflexes. When the
patients foot is abruptly dorsiflexed, it continues to beat two to three times
before settling into a resting position. How would the nurse document this
finding?
A) Rigidity
B) Flaccidity
C) Clonus
D) Ataxia: Ans: C
Feedback: When reflexes are very hyperactive, a phenomenon called clonus may be elicited. If the foot is abruptly
dorsiflexed, it may continue to beat two to three times before it settles into a position of rest. Rigidity is an increase in
muscle tone at rest characterized by increased resistance to passive stretch. Flaccidity is lack of muscle tone. Ataxia is
the inability to coordinate muscle movements, resulting in difficulty walking, talking, and performing self-care activities.
, Nursing 406 Unit 3 Nclex
Study online at https://quizlet.com/_hmbu7a
7. The nurse is doing an initial assessment on a patient newly admitted to
the unit with a diagnosis of cerebrovascular accident (CVA). The patient has
difficulty copying a figure that the nurse has drawn and is diagnosed with
visual-receptive aphasia. What brain region is primarily involved in this deficit?
A) Temporal lobe
B) Parietal-occipital area
C) Inferior posterior frontal areas
D) Posterior frontal area: Ans: B
Feedback: Difficulty copying a figure that the nurse has drawn would be considered visual-receptive aphasia, which
involves the parietal-occipital area. Expressive aphasia, the inability to express oneself, is often associated with damage
to the frontal area. Receptive aphasia, the inability to understand what someone else is saying, is often associated with
damage to the temporal lobe area.
8. What term is used to describe the fibrous connective tissue that hugs the
brain closely and extends into every fold of the brains surface?
A) Dura mater
B) Arachnoid
C) Fascia
D) Pia mater: Ans: D
Feedback: The term meninges describes the fibrous connective tissue that covers the brain and spinal cord. The
meninges have three layers, the dura mater, arachnoid, and pia mater. The pia mater is the innermost membrane that
hugs the brain closely and extends into every fold of the brains surface. The dura mater, the outermost layer, covers the
brain and spinal cord. The arachnoid, the middle membrane, is responsible for the production of cerebrospinal fluid.
9. The nurse is caring for a patient with an upper motor neuron lesion. What
clinical manifestations should the nurse anticipate when planning the patients
neurologic assessment?
A) Decreased muscle tone
B) Flaccid paralysis
C) Loss of voluntary control of movement
D) Slow reflexes: Ans: C
, Nursing 406 Unit 3 Nclex
Study online at https://quizlet.com/_hmbu7a
Feedback: Upper motor neuron lesions do not cause muscle atrophy, flaccid paralysis, or slow reflexes. However, upper
motor neuron lesions normally cause loss of voluntary control.
10. The nurse is admitting a patient to the unit who is diagnosed with a lower
motor neuron lesion. What entry in the patients electronic record is most
consistent with this diagnosis?
A) Patient exhibits increased muscle tone.
B) Patient demonstrates normal muscle structure with no evidence of atrophy.
C) Patient demonstrates hyperactive deep tendon reflexes.
D) Patient demonstrates an absence of deep tendon reflexes.: Ans: D
Feedback: Lower motor neuron lesions cause flaccid muscle paralysis, muscle atrophy, decreased muscle tone, and loss
of voluntary control
11. An elderly patient is being discharged home. The patient lives alone and has
atrophy of his olfactory organs. The nurse tells the patients family that it is
essential that the patient have what installed in the home?
A) Grab bars
B) Nonslip mats
C) Baseboard heaters
D) A smoke detector: Ans: D
Feedback: The sense of smell deteriorates with age. The olfactory organs are responsible for smell. This may present
a safety hazard for the patient because he or she may not smell smoke or gas leaks. Smoke detectors are universally
necessary, but especially for this patient.
12. The patient in the ED has just had a diagnostic lumbar puncture. To reduce
the incidence of a postlumbar puncture headache, what is the nurses most
appropriate action?
A) Position the patient prone.
B) Position the patient supine with the head of bed flat.
C) Position the patient left side-lying.
D) Administer acetaminophen as ordered: Ans: A
Feedback: The lumbar puncture headache may be avoided if a small-gauge needle is used and if the patient remains
