Chapter 60: Assessment: Nervous System |Harding: Lewis’s Medical-Surgical Nursing, 12th Edition

MULTIPLE CHOICE 1. When admitting an acutely confused patient with a head injury, which action would the nurse take? a. Ask family members about the patient‘s health history. b. Ask leading questions to assist in obtaining health data. c. Wait until the patient is better oriented to ask questions. d. Obtain only the physiologic neurologic assessment data. ANS: A When admitting a patient who is confused and likely to be a poor historian, the nurse would obtain health history information from others who have knowledge about the patient‘s health. Waiting until the patient is oriented or obtaining only physiologic data will result in incomplete assessment data, which could adversely affect decision making about treatment. Asking leading questions may result in inaccurate or incomplete information. DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. Which finding would the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion? a. Spasticity b. Flaccidity c. Impaired sensation d. Hyperactive reflexes ANS: B Lower motor neuron lesions generally cause weakness or paralysis, denervation atrophy, hyporeflexia or areflexia, and decreased muscle tone (flaccidity). Spasticity and hyperactive reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor neuron lesions. DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3. Which item would the nurse include in a focused assessment of a patient‘s left posterior temporal lobe functions? a. Sensation on the left side of the body b. Reasoning and problem-solving ability c. Ability to understand written and oral language d. Voluntary movements on the right side of the body ANS: C The posterior temporal lobe integrates the visual and auditory input for language comprehension. Reasoning and problem solving are functions of the anterior frontal lobe. Sensation on the left side of the body is located in the right postcentral gyrus. Voluntary movement on the right side is controlled in the left precentral gyrus. DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 4. How would the nurse assess the patient‘s trigeminal and facial nerve function (CNs V and VII)? a. Check for unilateral eyelid droop. b. Shine a light into the patient‘s pupil. c. Touch a cotton wisp strand to the cornea. d. Have the patient read a magazine or book. ANS: C The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to evaluate function of the oculomotor nerve. DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 5. Which action would the nurse include in the plan of care for a patient with impaired function of the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)? a. Assist to stand and ambulate. b. Withhold oral fluids and food. c. Insert an oropharyngeal airway. d. Apply artificial tears every hour. ANS: B The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. A patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve. Balance and coordination are cerebellar functions. DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 6. An unconscious patient has just arrived in the emergency department with a head injury caused by a motorcycle crash. Which planned intervention by the health care provider would the nurse question? a. Obtain x-rays of the skull and spine. b. Prepare the patient for lumbar puncture. c. Send for computed tomography (CT) scan. d. Perform neurologic checks every 15 minutes.