Chapter 14: Care of the Patient with a Neurologic Disorder
MULTIPLE CHOICE
1. What are the two divisions of the nervous system?
a. Somatic and the autonomic
b. Cerebellum and the brainstem
c. Medulla oblongata and the diencephalon
d. Central and the peripheral
ANS: D
The central and the peripheral are the two divisions of the nervous system. The autonomic and
the somatic are the division of the peripheral nervous system.
DIF: Cognitive Level: Knowledge REF: Page 671 OBJ: 1
TOP: Anatomy and physiology KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
2. What is the cranial nerve that supplies most of the organs in the thoracic and abdominal
cavities and also carries motor fibers to glands that produce digestive juices and other
secretions?
a. Somatic motor nerve
b. Visceral sensory nerve
c. Abducens nerve
d. Vagus nerve
ANS: D
The vagus nerve extends from the throat, larynx, and organs in the thoracic and abdominal
cavities. It is responsible for sensations and will accelerate peristalsis when stimulated.
DIF: Cognitive Level: Knowledge REF: Page 676, Table 14-1
OBJ: 5 TOP: Anatomy and physiology
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
3. The newly admitted patient to the emergency room 30 minutes ago after a fall off a ladder has
gradually decreased in consciousness and has slowly reacting pupils, a widening pulse
pressure, and verbal responses that are slow and unintelligible. What is the most appropriate
position for the patient?
a. Neck placed in a neutral position
b. Head raised slightly with hips flexed
c. Supine in gravity neutral position
d. Turn on right side with head elevated
ANS: A
Place the neck in a neutral position (not flexed or extended) to promote venous drainage.
DIF: Cognitive Level: Application REF: Page 690 OBJ: 12
TOP: Intracranial pressure (ICP) KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
, 4. Which question is likely to elicit the most valid response from the patient who is being
interviewed about a neurologic problem?
a. “Do you have any sensations of pins and needles in your feet?”
b. “Does the pain radiate from your back into your legs?”
c. “Can you describe the sensations you are having?”
d. “Do you ever have any nausea or dizziness?”
ANS: C
For patients with suspected neurologic conditions, the presence of many symptoms or
subjective data may be significant. Offering leading questions is not beneficial and may allow
the patient to give misinformation. Questions should be specific about symptoms.
DIF: Cognitive Level: Application REF: Page 677 OBJ: 8
TOP: Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. What is the cardinal sign of increased intracranial pressure in a brain injured patient?
a. Pupil changes
b. Ipsilateral paralysis
c. Vomiting
d. Decrease in the level of consciousness
ANS: D
Collection of objective data includes a change in level of consciousness. A change in the level
of consciousness is the earliest sign of increased intracranial pressure.
DIF: Cognitive Level: Analysis REF: Page 688 OBJ: 12
TOP: Intracranial pressure (ICP) KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
6. The nurse is aware that when assessing a patient by the FOUR score coma scale, the patient is
assessed in four categories: eye response, brainstem reflexes, motor response, and respiration.
How are these results reported?
a. As a sum of the scores of the four categories
b. As part of the Glasgow coma scale
c. As individual scores in each category
d. As progressive scores during a 24-hour period
ANS: C
The FOUR score coma scale assesses the patient in four categories: eye response, brainstem
reflexes, motor response, and respiration. The scores are reported as individual scores in each
category. It is frequently done in conjunction with the Glasgow coma scale, not part of it.
DIF: Cognitive Level: Comprehension REF: Page 769 OBJ: 11
TOP: FOUR Score Coma Scale KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
7. As the result of a stroke, a patient has difficulty discerning the position of his body without
looking at it. In the nurse’s documentation, which would best describe the patient’s inability to
assess spatial position of his body?
a. Agnosia
b. Proprioception
MULTIPLE CHOICE
1. What are the two divisions of the nervous system?
a. Somatic and the autonomic
b. Cerebellum and the brainstem
c. Medulla oblongata and the diencephalon
d. Central and the peripheral
ANS: D
The central and the peripheral are the two divisions of the nervous system. The autonomic and
the somatic are the division of the peripheral nervous system.
DIF: Cognitive Level: Knowledge REF: Page 671 OBJ: 1
TOP: Anatomy and physiology KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
2. What is the cranial nerve that supplies most of the organs in the thoracic and abdominal
cavities and also carries motor fibers to glands that produce digestive juices and other
secretions?
a. Somatic motor nerve
b. Visceral sensory nerve
c. Abducens nerve
d. Vagus nerve
ANS: D
The vagus nerve extends from the throat, larynx, and organs in the thoracic and abdominal
cavities. It is responsible for sensations and will accelerate peristalsis when stimulated.
DIF: Cognitive Level: Knowledge REF: Page 676, Table 14-1
OBJ: 5 TOP: Anatomy and physiology
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
3. The newly admitted patient to the emergency room 30 minutes ago after a fall off a ladder has
gradually decreased in consciousness and has slowly reacting pupils, a widening pulse
pressure, and verbal responses that are slow and unintelligible. What is the most appropriate
position for the patient?
a. Neck placed in a neutral position
b. Head raised slightly with hips flexed
c. Supine in gravity neutral position
d. Turn on right side with head elevated
ANS: A
Place the neck in a neutral position (not flexed or extended) to promote venous drainage.
DIF: Cognitive Level: Application REF: Page 690 OBJ: 12
TOP: Intracranial pressure (ICP) KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
, 4. Which question is likely to elicit the most valid response from the patient who is being
interviewed about a neurologic problem?
a. “Do you have any sensations of pins and needles in your feet?”
b. “Does the pain radiate from your back into your legs?”
c. “Can you describe the sensations you are having?”
d. “Do you ever have any nausea or dizziness?”
ANS: C
For patients with suspected neurologic conditions, the presence of many symptoms or
subjective data may be significant. Offering leading questions is not beneficial and may allow
the patient to give misinformation. Questions should be specific about symptoms.
DIF: Cognitive Level: Application REF: Page 677 OBJ: 8
TOP: Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. What is the cardinal sign of increased intracranial pressure in a brain injured patient?
a. Pupil changes
b. Ipsilateral paralysis
c. Vomiting
d. Decrease in the level of consciousness
ANS: D
Collection of objective data includes a change in level of consciousness. A change in the level
of consciousness is the earliest sign of increased intracranial pressure.
DIF: Cognitive Level: Analysis REF: Page 688 OBJ: 12
TOP: Intracranial pressure (ICP) KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
6. The nurse is aware that when assessing a patient by the FOUR score coma scale, the patient is
assessed in four categories: eye response, brainstem reflexes, motor response, and respiration.
How are these results reported?
a. As a sum of the scores of the four categories
b. As part of the Glasgow coma scale
c. As individual scores in each category
d. As progressive scores during a 24-hour period
ANS: C
The FOUR score coma scale assesses the patient in four categories: eye response, brainstem
reflexes, motor response, and respiration. The scores are reported as individual scores in each
category. It is frequently done in conjunction with the Glasgow coma scale, not part of it.
DIF: Cognitive Level: Comprehension REF: Page 769 OBJ: 11
TOP: FOUR Score Coma Scale KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
7. As the result of a stroke, a patient has difficulty discerning the position of his body without
looking at it. In the nurse’s documentation, which would best describe the patient’s inability to
assess spatial position of his body?
a. Agnosia
b. Proprioception
