Chapter 60 Assessment: Nervous System Questions With Correct Verified Answers

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. - correct answers a. Ask family members about the patient's health history. 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. 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 - correct answers b. Flaccidity 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. 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 - correct answers c. Ability to understand written and oral language 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. 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. - correct answers c. Touch a cotton wisp strand to the cornea. 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. 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. - correct answers b. Withhold oral fluids and food. 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. 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. - correct answers b. Prepare the patient for lumbar puncture. After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure. Herniation of the brain could result if lumbar puncture is performed. The other orders are appropriate. A patient with suspected meningitis is scheduled for a lumbar puncture. What action would the nurse take before the procedure? 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. - correct answers d. Help the patient to a lateral position. 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. During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurse's directions to move his hands and feet. Which condition would the nurse suspect as a likely cause of these findings? a. Cerebellar injury b. A brainstem lesion c. Frontal lobe damage d. A temporal lobe lesion - correct answers c. Frontal lobe damage Expressive speech (ability to express the self in language) is controlled by Broca's area in the frontal lobe. The temporal lobe contains Wernicke's area, which is responsible for receptive speech (ability to understand language input). The cerebellum and brainstem do not affect higher cognitive functions such as speech. A patient has a tumor in the cerebellum. Which goal would the nurse use to focus the plan of care? a. Prevent falls. b. Stabilize mood. c. Avoid aspiration. d. Improve memory. - correct answers a. Prevent falls. 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. Which problem would the nurse expect for a patient who has a positive Romberg test result? a. Pain b. Falls c. Aphasia d. Confusion - correct answers b. Falls