NR 463 Med Sure 1 Final Exam Questions With
Complete Answers
1. When admitting an acutely confused patient with a head injury, which action should
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. - ANSWER Ask family
members about the patient's health history.
A patient has a lesion that affects lower motor neurons. During assessment of the
patient's lower extremities, the nurse expects to find
a.
spasticity.
b.
flaccidity.
c.
loss of sensation.
d.
hyperactive reflexes. - ANSWER b.
flaccidity.
The following orders are received for an unconscious patient who has just arrived in the
emergency department after a head injury caused by an automobile accident. Which
one 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. - ANSWER b.
Prepare the patient for lumbar puncture.
A patient is scheduled for a lumbar puncture. The nurse will plan to
a.
transfer the patient to radiology just before the procedure.
b.
help the patient to a side lying position before the procedure.
c.
place the patient on NPO status for 4 hours before the procedure.
d.
administer a sedative medication 30 minutes before the procedure. - ANSWER b.
help the patient to a side lying position before the procedure.
During the neurologic assessment, the patient cooperates with the nurse's directions to
grip with the hands and to move the feet but is unable to respond orally to the nurse's
questions. The nurse will suspect
a.
a brainstem lesion.
b.
a temporal lobe lesion.
c.
injury to the cerebellum.
,d.
damage to the frontal lobe. - ANSWER d.
damage to the frontal lobe.
When developing a plan of care for a patient with dysfunction of the cerebellum, the
nurse will include interventions to
a.
prevent falls.
b.
stabilize mood.
c.
enhance swallowing ability.
d.
improve short-term memory. - ANSWER a.
prevent falls.
Which equipment will the nurse obtain to assess vibration sense in a patient who has
peripheral nerve dysfunction?
a.
Sharp pin
b.
Tuning fork
c.
Reflex hammer
d.
Calibrated compass - ANSWER b.
Tuning fork
, The charge nurse is observing a new staff nurse who is assessing a patient with a
possible spinal cord lesion for sensation. Which action indicates a need for further
teaching about neurologic assessment?
a.
The new nurse asks the patient, "Does this feel sharp?"
b.
The new nurse tests for light touch before testing for pain.
c.
The new nurse has the patient close the eyes during testing.
d.
The new nurse uses an irregular pattern to test for intact touch. - ANSWER a.
The new nurse asks the patient, "Does this feel sharp?"
A patient with a brainstem infarction is admitted to the nursing unit. The priority nursing
assessment for the patient is
a.
reflex reaction time.
b.
pupil reaction to light.
c.
level of consciousness.
d.
respiratory rate and rhythm. - ANSWER d.
respiratory rate and rhythm.
Which assessments will the nurse make to test a patient's cerebellar function (select all
that apply)?
a.
Assess for graphesthesia.
Complete Answers
1. When admitting an acutely confused patient with a head injury, which action should
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. - ANSWER Ask family
members about the patient's health history.
A patient has a lesion that affects lower motor neurons. During assessment of the
patient's lower extremities, the nurse expects to find
a.
spasticity.
b.
flaccidity.
c.
loss of sensation.
d.
hyperactive reflexes. - ANSWER b.
flaccidity.
The following orders are received for an unconscious patient who has just arrived in the
emergency department after a head injury caused by an automobile accident. Which
one 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. - ANSWER b.
Prepare the patient for lumbar puncture.
A patient is scheduled for a lumbar puncture. The nurse will plan to
a.
transfer the patient to radiology just before the procedure.
b.
help the patient to a side lying position before the procedure.
c.
place the patient on NPO status for 4 hours before the procedure.
d.
administer a sedative medication 30 minutes before the procedure. - ANSWER b.
help the patient to a side lying position before the procedure.
During the neurologic assessment, the patient cooperates with the nurse's directions to
grip with the hands and to move the feet but is unable to respond orally to the nurse's
questions. The nurse will suspect
a.
a brainstem lesion.
b.
a temporal lobe lesion.
c.
injury to the cerebellum.
,d.
damage to the frontal lobe. - ANSWER d.
damage to the frontal lobe.
When developing a plan of care for a patient with dysfunction of the cerebellum, the
nurse will include interventions to
a.
prevent falls.
b.
stabilize mood.
c.
enhance swallowing ability.
d.
improve short-term memory. - ANSWER a.
prevent falls.
Which equipment will the nurse obtain to assess vibration sense in a patient who has
peripheral nerve dysfunction?
a.
Sharp pin
b.
Tuning fork
c.
Reflex hammer
d.
Calibrated compass - ANSWER b.
Tuning fork
, The charge nurse is observing a new staff nurse who is assessing a patient with a
possible spinal cord lesion for sensation. Which action indicates a need for further
teaching about neurologic assessment?
a.
The new nurse asks the patient, "Does this feel sharp?"
b.
The new nurse tests for light touch before testing for pain.
c.
The new nurse has the patient close the eyes during testing.
d.
The new nurse uses an irregular pattern to test for intact touch. - ANSWER a.
The new nurse asks the patient, "Does this feel sharp?"
A patient with a brainstem infarction is admitted to the nursing unit. The priority nursing
assessment for the patient is
a.
reflex reaction time.
b.
pupil reaction to light.
c.
level of consciousness.
d.
respiratory rate and rhythm. - ANSWER d.
respiratory rate and rhythm.
Which assessments will the nurse make to test a patient's cerebellar function (select all
that apply)?
a.
Assess for graphesthesia.
