Chapter 56: Nursing Assessment: Nervous System

Test Bank

MULTIPLE CHOICE

1. When admitting an acutely confused 20-year-old patient with a head injury, which action
should the nurse take?
a. Ask family members about the patients 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 likely to be a poor historian, the nurse should obtain health
history information from others who have knowledge about the patients 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) REF: 1343

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.No 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: Understand (comprehension) REF: 1338

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

3. The nurse performing a focused assessment of left posterior temporal lobe functions will
assess the patient for
a. sensation on the left side of the body.
b. voluntary movements on the right side.
c. reasoning and problem-solving abilities.
d. understanding 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: Apply (application) REF: 1339
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

4. Propranolol (Inderal), a b-adrenergic blocker that inhibits sympathetic nervous system

activity, is prescribed for a patient who has extreme anxiety about public speaking. The nurse
monitors the patient for
a. dry mouth.
b. bradycardia.
c. constipation.
d. urinary retention.
ANS: B
Inhibition of the fight or flight response leads to a decreased heart rate. Dry mouth,
constipation, and urinary retention are associated with peripheral nervous system blockade.

DIF: Cognitive Level: Understand (comprehension) REF: eTable 56-2

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

5. To assess the functioning of the trigeminal and facial nerves (CNs V and VII), the nurse
should
a. shine a light into the patients pupil.
b. check for unilateral eyelid drooping.
c. touch a cotton wisp strand to the cornea.
d. have the patient read a magazine or book.
ANS: A
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 check function of the oculomotor nerve.

DIF: Cognitive Level: Understand (comprehension) REF: 1347

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

6. Which action will the nurse include in the plan of care for a patient with impaired functioning
of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X)?
a. Withhold oral fluid or foods.
b. Provide highly seasoned foods.
c. Insert an oropharyngeal airway.
d. Apply artificial tears every hour.
ANS: A
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.

DIF: Cognitive Level: Apply (application) REF: 1347

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

7. An unconscious male patient has just arrived in the emergency department after a head injury
caused by a motorcycle crash. Which order should 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.
ANS: B
After a head injury, the patient may be experiencing intracranial bleeding and increased
intracranial pressure, which could lead to herniation of the brain if a lumbar puncture is
performed. The other orders are appropriate.

DIF: Cognitive Level: Apply (application) REF: 1349 | 1352

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

8. A patient with suspected meningitis is scheduled for a lumbar puncture. Before the procedure,
the nurse will plan to
a. enforce NPO status for 4 hours.
b. transfer the patient to radiology.
c. administer a sedative medication.
d. help the patient to a lateral position.
ANS: D
For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does
not usually require a sedative, is done in the patient room, and has no risk for aspiration.

DIF: Cognitive Level: Apply (application) REF: 1352

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

9. During the neurologic assessment, the patient is unable to respond verbally to the nurse but
cooperates with the nurses directions to move his hands and feet. The nurse will suspect
a. cerebellar injury.
b. a brainstem lesion.
c. frontal lobe damage.
d. a temporal lobe lesion.
ANS: C
Expressive speech is controlled by Brocas area in the frontal lobe. The temporal lobe contains
Wernickes area, which is responsible for receptive speech. The cerebellum and brainstem do
not affect higher cognitive functions such as speech.

DIF: Cognitive Level: Apply (application) REF: 1339

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

10. A 45-year-old patient has a dysfunction of the cerebellum. The nurse will plan interventions to
a. prevent falls.
b. stabilize mood.
c. avoid aspiration.
d. improve memory.
ANS: A
Because functions of the cerebellum include coordination and balance, the patient with
dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing
ability.
 DIF: Cognitive Level: Apply (application) REF: 1339-1340
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

11. Which nursing diagnosis is expected to be appropriate for a patient who has a positive
Romberg test?
a. Acute pain
b. Risk for falls
c. Acute confusion
d. Ineffective thermoregulation
ANS: B
A positive Romberg test indicates that the patient has difficulty maintaining balance with the
eyes closed. The Romberg does not test for orientation, thermoregulation, or discomfort.

DIF: Cognitive Level: Apply (application) REF: 1348

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

12. The nurse will anticipate teaching a patient with a possible seizure disorder about which test?
a. Cerebral angiography
b. Evoked potential studies
c. Electromyography (EMG)
d. Electroencephalography (EEG)
ANS: D
Seizure disorders are usually assessed using EEG testing. Evoked potential is used for
diagnosing problems with the visual or auditory systems. Cerebral angiography is used to
diagnose vascular problems. EMG is used to evaluate electrical innervation to skeletal muscle.

DIF: Cognitive Level: Understand (comprehension) REF: 1351

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

13. Which nursing action will be included in the care for a patient who has had cerebral
angiography?
a. Monitor for headache and photophobia.
b. Keep patient NPO until gag reflex returns.
c. Check pulse and blood pressure frequently.
d. Assess orientation to person, place, and time.
ANS: C
Because a catheter is inserted into an artery (such as the femoral artery) during cerebral
angiography, the nurse should assess for bleeding after this procedure. The other nursing
assessments are not necessary after angiography.

DIF: Cognitive Level: Apply (application) REF: 1351

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

14. Which equipment will the nurse obtain to assess vibration sense in a diabetic patient who has
peripheral nerve dysfunction?
a. Sharp pin
b. Tuning fork
c. Reflex hammer
 d. Calibrated compass
ANS: B
Vibration sense is testing by touching the patient with a vibrating tuning fork. The other
equipment is needed for testing of pain sensation, reflexes, and two-point discrimination.

DIF: Cognitive Level: Understand (comprehension) REF: 1348

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

15. Which information about a 76-year-old patient is most important for the admitting nurse to
report to the patients health care provider?
a. Triceps reflex response graded at 1/5
b. Unintended weight loss of 20 pounds
c. 10 mm Hg orthostatic drop in systolic blood pressure
d. Patient complaint of chronic difficulty in falling asleep
ANS: B
Although changes in appetite are normal with aging, a 20-pound weight loss requires further
investigation. Orthostatic drops in blood pressure, changes in sleep patterns, and slowing of
reflexes are normal changes in aging.

DIF: Cognitive Level: Apply (application) REF: 1343-1344

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance

16. The charge nurse is observing a new staff nurse who is assessing a patient with a traumatic
spinal cord injury for sensation. Which action indicates a need for further teaching of the new
nurse about neurologic assessment?
a. The new nurse tests for light touch before testing for pain.
b. The new nurse has the patient close the eyes during testing.
c. The new nurse asks the patient if the instrument feels sharp.
d. The new nurse uses an irregular pattern to test for intact touch.
ANS: C
When performing a sensory assessment, the nurse should not provide verbal clues. The other
actions by the new nurse are appropriate.

DIF: Cognitive Level: Apply (application) REF: 1328

OBJ: Special Questions: Delegation TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment

17. Which cerebrospinal fluid analysis result will be most important for the nurse to communicate
to the health care provider?
a. Specific gravity 1.007
b. Protein 65 mg/dL (0.65 g/L)
c. Glucose 45 mg/dL (1.7 mmol/L)
d. White blood cell (WBC) count 4 cells/mL
ANS: B
The protein level is high. The specific gravity, WBCs, and glucose values are normal.

DIF: Cognitive Level: Understand (comprehension) REF: 1353

 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

18. A 39-year-old patient with a suspected herniated intervertebral disc is scheduled for a
myelogram. Which information is most important for the nurse to communicate to the health
care provider before the procedure?
a. The patient is anxious about the test.
b. The patient has an allergy to shellfish.
c. The patient has back pain when lying flat.
d. The patient drank apple juice 4 hours earlier.
ANS: B
Iodine-containing contrast medium is injected into the subarachnoid space during a
myelogram. The health care provider may need to modify the postmyelogram orders to
prevent back pain, but this can be done after the procedure. Clear liquids are usually
considered safe up to 4 hours before a diagnostic or surgical procedure. The patients anxiety
should be addressed, but this is not as important as the iodine allergy.

DIF: Cognitive Level: Apply (application) REF: 1352

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity

19. The priority nursing assessment for a 72-year-old patient being admitted with a brainstem
infarction is
a. reflex reaction time.
b. pupil reaction to light.
c. level of consciousness.
d. respiratory rate and rhythm.
ANS: D
Vital centers that control respiration are located in the medulla, and these are the priority
assessments because changes in respiratory function may be life threatening. The other
information will also be collected by the nurse, but it is not as urgent.

DIF: Cognitive Level: Apply (application) REF: 1339

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity

20. Several patients have been hospitalized for diagnosis of neurologic problems. Which patient
will the nurse assess first?
a. Patient with a transient ischemic attack (TIA) returning from carotid duplex
studies
b. Patient with a brain tumor who has just arrived on the unit after a cerebral
angiogram
c. Patient with a seizure disorder who has just completed an electroencephalogram
(EEG)
d. Patient prepared for a lumbar puncture whose health care provider is waiting for
assistance
ANS: B
 Because cerebral angiograms require insertion of a catheter into the femoral artery, bleeding is
a possible complication. The nurse will need to check the pulse, blood pressure, and the
catheter insertion site in the groin as soon as the patient arrives. Carotid duplex studies and
EEG are noninvasive. The nurse will need to assist with the lumbar puncture as soon as
possible, but monitoring for hemorrhage after cerebral angiogram has a higher priority.

DIF: Cognitive Level: Analyze (analysis) REF: 1351-1352

OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. Which assessments will the nurse make to monitor a patients cerebellar function (select all
that apply)?
a. Assess for graphesthesia.
b. Observe arm swing with gait.
c. Perform the finger-to-nose test.
d. Check ability to push against resistance.
e. Determine ability to sense heat and cold.
ANS: B, C
The cerebellum is responsible for coordination and is assessed by looking at the patients gait
and the finger-to-nose test. The other assessments will be used for other parts of the
neurologic assessment.

DIF: Cognitive Level: Analyze (analysis) REF: 1348

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance