C HAPTER 22: N EUROLOGIC C LINICAL
A SSESSMENT AND D IAGNOSTIC
P ROCEDURES
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. Considering anatomic location, which cranial nerve will be affected first
by downward pressure onto the infratentorial structures?
a. III
b. VI
c. IX
d. X
ANS: A
With the l ocation of the oculomotor nerve (cranial nerve [CN] III) at
the notch of the tentorium, pupil size, and reactivit y play a key role in
the physical assessment of intracranial pressure changes and herniation
s yndromes. In addition to CN III compression, chan ges in pupil size
occur for other reasons. Large pupils can result from the instillation of
cycloplegic agents, such as atropine or scopolamine, or can indicate
extreme stress. Extremel y small pupils can indicate narcotic overdose,
lower brainstem compress ion, or bilateral damage to the pons.
, PTS: 1 DIF: Cognitive Level: Understanding REF: p.
554 OBJ: Nursing Process Step: Diagnosis TOP:
Neurologic MSC: NC LEX: Physiologic Integrit y
2. A patient has been admitted with acute confusion and other focal
neurologic signs. The provider is planning to perform a lumbar puncture.
What is an abnormal finding in the cerebrospinal fluid?
a. Clear and colorless
b. Glucose of 60 mg/dL
c. Protein of 20 mg/dL
d. 30 mg/dL red blood cells
ANS: D
Cerebrospinal fluid is normall y a c lear, colorless, odorless solution
that contains 50 to 75 mg/dL of glucose, 5 to 25 mg/dL of protein, and
no red blood cells.
PTS: 1 DIF: Cognitive Level: Appl ying REF: p. 568 |
Table 22-5 OBJ: Nursing Process Step: Assessment TOP:
Neurologic MSC: NC LEX: Physiologic Integrit y
3. Which procedure is the diagnostic study of choice for acute head injury?
a. Magnetic resonance imaging
b. Computed tomography
c. Transcranial Doppler
d. Electroencephalography
, ANS: B
Computed tomography offers rapid, convenient, noninvas ive
visualization of structures and is the diagnostic study of choice for an
acute head injury.
PTS: 1 DIF: Cognitive Level: Remembering REF: p. 560
OBJ: Nursing Process Step: Diagnosis TOP:
Neurologic MSC: NC LEX: Physiologic Integrit y
4. A patient has been admitted with acute confusion and other focal
neurologic signs. The provider orders magnetic resonance imaging (MR I).
Which physiological problem is the MR I superior to the computed
tomography CT as a diagnostic tool?
a. Brain death determination
b. Detection of central nervous system infection
c. Estimation of intracranial pressure
d. Identification of subarachnoid hemorrhage
ANS: B
Magnetic resonance imaging (MR I) produces images with greater detail
than computed tomography (CT) and provides views of several planes
(sagittal, coronal, axial, and oblique) that are not possible with CT.
MRI with contrast is the preferred study for detection of infectious and
inflammatory processes of the central nervous system (CNS). MRI can
detect areas of cerebral infarct wit hin a few hours of the incident and
can identify small areas of plaque in patients with multiple sclerosis.
MRI with contrast is the preferred study for detection of infectious and
inflammatory processes of the CNS, malignancy, and metastatic
, lesions; cervical spine imaging; and postoperative evaluation of tumor
recurrence. MR I also is the diagnostic study of choice in the evaluation
of spinal cord injury.
PTS: 1 DIF: Cognitive Level: Understanding REF: p.
560 OBJ: Nursing Process Step: Diagnosis TOP:
Neurologic MSC: NC LEX: Physiologic Integrit y
5. A patient is having a digital subtraction angiography. Which instruction is
included for the patient to prepare for the procedure ?
a. Inform the patient that the procedure is very noisy and earplugs will
be provided
b. Tell the patient that repositioning will be required at appropriate
intervals
c. Instruct the patient to remaining motionless during the entire
procedure
d. Let the patient know he will be expected to swallow frequently
during the procedure
ANS: C
The major disadvantage of digital subtraction angiography involves the
patient’s abilit y to remain motionless during the entire procedure. Even
swallowing significantl y interferes with the imaging process.
PTS: 1 DIF: Cognitive Level: Remembering REF: p. 564
OBJ: Nursing Process Step: Diagnosis TOP:
Neurologic MSC: NC LEX: Physiologic Integrit y
A SSESSMENT AND D IAGNOSTIC
P ROCEDURES
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. Considering anatomic location, which cranial nerve will be affected first
by downward pressure onto the infratentorial structures?
a. III
b. VI
c. IX
d. X
ANS: A
With the l ocation of the oculomotor nerve (cranial nerve [CN] III) at
the notch of the tentorium, pupil size, and reactivit y play a key role in
the physical assessment of intracranial pressure changes and herniation
s yndromes. In addition to CN III compression, chan ges in pupil size
occur for other reasons. Large pupils can result from the instillation of
cycloplegic agents, such as atropine or scopolamine, or can indicate
extreme stress. Extremel y small pupils can indicate narcotic overdose,
lower brainstem compress ion, or bilateral damage to the pons.
, PTS: 1 DIF: Cognitive Level: Understanding REF: p.
554 OBJ: Nursing Process Step: Diagnosis TOP:
Neurologic MSC: NC LEX: Physiologic Integrit y
2. A patient has been admitted with acute confusion and other focal
neurologic signs. The provider is planning to perform a lumbar puncture.
What is an abnormal finding in the cerebrospinal fluid?
a. Clear and colorless
b. Glucose of 60 mg/dL
c. Protein of 20 mg/dL
d. 30 mg/dL red blood cells
ANS: D
Cerebrospinal fluid is normall y a c lear, colorless, odorless solution
that contains 50 to 75 mg/dL of glucose, 5 to 25 mg/dL of protein, and
no red blood cells.
PTS: 1 DIF: Cognitive Level: Appl ying REF: p. 568 |
Table 22-5 OBJ: Nursing Process Step: Assessment TOP:
Neurologic MSC: NC LEX: Physiologic Integrit y
3. Which procedure is the diagnostic study of choice for acute head injury?
a. Magnetic resonance imaging
b. Computed tomography
c. Transcranial Doppler
d. Electroencephalography
, ANS: B
Computed tomography offers rapid, convenient, noninvas ive
visualization of structures and is the diagnostic study of choice for an
acute head injury.
PTS: 1 DIF: Cognitive Level: Remembering REF: p. 560
OBJ: Nursing Process Step: Diagnosis TOP:
Neurologic MSC: NC LEX: Physiologic Integrit y
4. A patient has been admitted with acute confusion and other focal
neurologic signs. The provider orders magnetic resonance imaging (MR I).
Which physiological problem is the MR I superior to the computed
tomography CT as a diagnostic tool?
a. Brain death determination
b. Detection of central nervous system infection
c. Estimation of intracranial pressure
d. Identification of subarachnoid hemorrhage
ANS: B
Magnetic resonance imaging (MR I) produces images with greater detail
than computed tomography (CT) and provides views of several planes
(sagittal, coronal, axial, and oblique) that are not possible with CT.
MRI with contrast is the preferred study for detection of infectious and
inflammatory processes of the central nervous system (CNS). MRI can
detect areas of cerebral infarct wit hin a few hours of the incident and
can identify small areas of plaque in patients with multiple sclerosis.
MRI with contrast is the preferred study for detection of infectious and
inflammatory processes of the CNS, malignancy, and metastatic
, lesions; cervical spine imaging; and postoperative evaluation of tumor
recurrence. MR I also is the diagnostic study of choice in the evaluation
of spinal cord injury.
PTS: 1 DIF: Cognitive Level: Understanding REF: p.
560 OBJ: Nursing Process Step: Diagnosis TOP:
Neurologic MSC: NC LEX: Physiologic Integrit y
5. A patient is having a digital subtraction angiography. Which instruction is
included for the patient to prepare for the procedure ?
a. Inform the patient that the procedure is very noisy and earplugs will
be provided
b. Tell the patient that repositioning will be required at appropriate
intervals
c. Instruct the patient to remaining motionless during the entire
procedure
d. Let the patient know he will be expected to swallow frequently
during the procedure
ANS: C
The major disadvantage of digital subtraction angiography involves the
patient’s abilit y to remain motionless during the entire procedure. Even
swallowing significantl y interferes with the imaging process.
PTS: 1 DIF: Cognitive Level: Remembering REF: p. 564
OBJ: Nursing Process Step: Diagnosis TOP:
Neurologic MSC: NC LEX: Physiologic Integrit y
