Chapter 58: Nursing Assessment: Nervous System
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is admitting a client with a head injury who is acutely confused. Which of the
following actions should the nurse take?
a. Ask family members about the client’s health history.
b. Ask leading questions to assist in obtaining health data.
c. Wait until the client is better oriented to ask questions.
d. Obtain only the physiologic neurological assessment data.
ANS: A
When admitting a client who is likely to be a poor historian, the nurse should obtain health
history information from others who have knowledge about the client’s health. Waiting
until the client is oriented or obtaining only physiological data will result in incomplete
assessment data; this could adversely affect decision-making about treatment. Asking
leading questions may result in inaccurate or incomplete information.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
2. A client has a lesion that affects lower motor neurons. During assessment of the client’s
lower extremities, which of the following findings should the nurse expect?
a. Spasticity
b. Flaccidity
c. Loss of sensation
d. Hyperactive reflexes
ANS: B
Because the cell bodies of lower motor neurons are located in the spinal cord, damage to
the neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive
reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor
neuron lesions.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
3. The nurse is performing a focused assessment on a client with a lesion of the left posterior
temporal lobe. Which of the following assessments should the nurse complete?
a. Sensation on the left side of the body
b. Voluntary movement on the right side
c. Reasoning and problem-solving abilities
d. Understanding of written and oral language
ANS: D
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: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
4. Propranolol, a b-adrenergic blocker that inhibits sympathetic nervous system activity, is
prescribed for a client. Which of the following assessments should the nurse monitor?
a. Dry mouth
b. Constipation
c. Slowed pulse
d. Urinary retention
ANS: C
Inhibition of the fight or flight response leads to decreased heart rate. Dry mouth,
constipation, and urinary retention are associated with peripheral nervous system
blockade.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
5. Which of the following actions should the nurse implement to assess the functioning of the
trigeminal and facial nerves (CN V and VII) in a client?
a. Apply a cotton wisp strand to the cornea.
b. Have the client read a magazine or book.
c. Shine a bright light into the client’s pupil.
d. Check for unilateral drooping of the eyelids.
ANS: A
The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is
tested by having the client read a Snellen chart or a newspaper. Assessment of pupil
response to light and ptosis are used to check function of the oculomotor nerve.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
6. Neurological testing of the client indicates impaired functioning of the left
glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). Which of the following
actions should the nurse include in the plan of care?
a. Insert an oral airway.
b. Withhold oral fluid or foods.
c. Provide highly seasoned foods.
d. Apply artificial tears every hour.
ANS: B
The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex; a
client with impaired function of these nerves is at risk for aspiration. An oral airway may
be needed when a client 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.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is admitting a client with a head injury who is acutely confused. Which of the
following actions should the nurse take?
a. Ask family members about the client’s health history.
b. Ask leading questions to assist in obtaining health data.
c. Wait until the client is better oriented to ask questions.
d. Obtain only the physiologic neurological assessment data.
ANS: A
When admitting a client who is likely to be a poor historian, the nurse should obtain health
history information from others who have knowledge about the client’s health. Waiting
until the client is oriented or obtaining only physiological data will result in incomplete
assessment data; this could adversely affect decision-making about treatment. Asking
leading questions may result in inaccurate or incomplete information.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
2. A client has a lesion that affects lower motor neurons. During assessment of the client’s
lower extremities, which of the following findings should the nurse expect?
a. Spasticity
b. Flaccidity
c. Loss of sensation
d. Hyperactive reflexes
ANS: B
Because the cell bodies of lower motor neurons are located in the spinal cord, damage to
the neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive
reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor
neuron lesions.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
3. The nurse is performing a focused assessment on a client with a lesion of the left posterior
temporal lobe. Which of the following assessments should the nurse complete?
a. Sensation on the left side of the body
b. Voluntary movement on the right side
c. Reasoning and problem-solving abilities
d. Understanding of written and oral language
ANS: D
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: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
4. Propranolol, a b-adrenergic blocker that inhibits sympathetic nervous system activity, is
prescribed for a client. Which of the following assessments should the nurse monitor?
a. Dry mouth
b. Constipation
c. Slowed pulse
d. Urinary retention
ANS: C
Inhibition of the fight or flight response leads to decreased heart rate. Dry mouth,
constipation, and urinary retention are associated with peripheral nervous system
blockade.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
5. Which of the following actions should the nurse implement to assess the functioning of the
trigeminal and facial nerves (CN V and VII) in a client?
a. Apply a cotton wisp strand to the cornea.
b. Have the client read a magazine or book.
c. Shine a bright light into the client’s pupil.
d. Check for unilateral drooping of the eyelids.
ANS: A
The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is
tested by having the client read a Snellen chart or a newspaper. Assessment of pupil
response to light and ptosis are used to check function of the oculomotor nerve.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
6. Neurological testing of the client indicates impaired functioning of the left
glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). Which of the following
actions should the nurse include in the plan of care?
a. Insert an oral airway.
b. Withhold oral fluid or foods.
c. Provide highly seasoned foods.
d. Apply artificial tears every hour.
ANS: B
The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex; a
client with impaired function of these nerves is at risk for aspiration. An oral airway may
be needed when a client 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.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
