NEW!!NEURO ALL $ EXAM 1 MS2
LEWIS 10TH
NEURO
Chapter 55: Assessment of Nervous System
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
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.
ANS: A
,NEW!!NEURO ALL $ EXAM 1 MS2
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
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.
DIF: Cognitive Level: Apply (application) REF:1301
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 c. Impaired sensation
b. Flaccidity d. Hyperactive reflexes
ANS: B
,NEW!!NEURO ALL $ EXAM 1 MS2
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:
1296
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. reasoning and problem-solving ability.
c. ability to understand written and oral language.
d. voluntary movements on the right side of the body.
, NEW!!NEURO ALL $ EXAM 1 MS2
ANS: C
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:1298
TOP: Nursing Process: Assessment MSC: NCLEX:
Physiological Integrity
4. Propranolol (Inderal), a -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. c. constipation.
b. bradycardia. d. urinary retention.
ANS: B
LEWIS 10TH
NEURO
Chapter 55: Assessment of Nervous System
Lewis: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
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.
ANS: A
,NEW!!NEURO ALL $ EXAM 1 MS2
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
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.
DIF: Cognitive Level: Apply (application) REF:1301
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 c. Impaired sensation
b. Flaccidity d. Hyperactive reflexes
ANS: B
,NEW!!NEURO ALL $ EXAM 1 MS2
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:
1296
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. reasoning and problem-solving ability.
c. ability to understand written and oral language.
d. voluntary movements on the right side of the body.
, NEW!!NEURO ALL $ EXAM 1 MS2
ANS: C
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:1298
TOP: Nursing Process: Assessment MSC: NCLEX:
Physiological Integrity
4. Propranolol (Inderal), a -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. c. constipation.
b. bradycardia. d. urinary retention.
ANS: B
