Chapter 21: The Neurologic System
deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition
MULTIPLE CHOICE
1.The nurse is caring for the patient who has had an injury to the hypothalamus. Which intervention is most important for the nurse to implement?
a.Closely control room temperature.
b.Monitor for signs of hemorrhage.
c.Protect the patient’s eyes from bright lights.
d.Turn the patient hourly to maintain skin integrity.
ANS: A
The hypothalamus regulates body temperature; therefore, it is important to maintain adequate temperature control of the environment since the body’s ability to regulate the temperature will be affected by injury to the organ. Bleeding, photophobia, and skin integrity are not issues associated with the hypothalamus.
PTS:1 DIF: Cognitive Level: Application REF: 473, Table 21-1
OBJ:6 (theory) TOP: Hypothalamus
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
2.The nurse differentiates the sympathetic from the parasympathetic nervous systems. Which statement about the sympathetic system is accurate? a.The sympathetic system provides energy for “fight or flight” in stressful situations.
b.The sympathetic system slows the heart rate after a stressful situation.
c.The sympathetic system supports deep sleep after large expenditures of energy.
d.The sympathetic system relaxes blood vessels to counteract hypertension.
ANS: A
The sympathetic nervous system “gears up” the body for “fight or flight” situations with epinephrine that will raise the blood pressure (BP), reduce bowel motility, and energize the whole body to defend itself in a stressful situation. The parasympathetic system slows the heart rate after stress, supports deep sleep, and relaxes blood vessels.
PTS:1 DIF: Cognitive Level: Knowledge REF:475, Table 21-3
OBJ:2 (theory) TOP: Sympathetic Nervous System
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3.The nurse is assessing an 80-year-old patient. The nurse correctly attributes the slowed knee jerk reflex with which age- related change?
a.Diminished brain cells
b.Degeneration of myelin sheath
c.Weakened muscles
d.Irritation of nerve roots
ANS: B
In the peripheral nervous system (PNS), the motor nerve fibers and the myelin sheath degenerate with advancing age;
reflexes may become diminished or absent with advanced age. PTS:1DIF: Cognitive Level: Comprehension REF:484
OBJ:2 (theory) TOP: PNS: Diminished Reflexes
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4.A student nurse questions the nurse about the difference between a quadriplegic and a tetraplegic patient. Which statement correctly describes tetraplegia?
a.Tetraplegic patients are capable of fewer fine motor movements.
b.Tetraplegic patients can experience pain in paralyzed parts.
c.Tetraplegic patients are more easily rehabilitated.
d.Tetraplegia is the newer term for the old term quadriplegia. ANS: D
Tetraplegia is the newer term for the old term quadriplegia.
PTS:1DIF: Cognitive Level: Knowledge REF:492
OBJ:1 (theory) TOP: Tetraplegia vs. Quadriplegia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5.The nurse is performing a neurologic assessment on a patient. Which action should the nurse take to adequately test the effectiveness for the hypoglossal nerve?
a.Ask the patient to touch the tip of the tongue to each cheek.
b.Check air movement through each nostril separately.
c.Ask the patient to wrinkle the forehead.
deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition
MULTIPLE CHOICE
1.The nurse is caring for the patient who has had an injury to the hypothalamus. Which intervention is most important for the nurse to implement?
a.Closely control room temperature.
b.Monitor for signs of hemorrhage.
c.Protect the patient’s eyes from bright lights.
d.Turn the patient hourly to maintain skin integrity.
ANS: A
The hypothalamus regulates body temperature; therefore, it is important to maintain adequate temperature control of the environment since the body’s ability to regulate the temperature will be affected by injury to the organ. Bleeding, photophobia, and skin integrity are not issues associated with the hypothalamus.
PTS:1 DIF: Cognitive Level: Application REF: 473, Table 21-1
OBJ:6 (theory) TOP: Hypothalamus
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
2.The nurse differentiates the sympathetic from the parasympathetic nervous systems. Which statement about the sympathetic system is accurate? a.The sympathetic system provides energy for “fight or flight” in stressful situations.
b.The sympathetic system slows the heart rate after a stressful situation.
c.The sympathetic system supports deep sleep after large expenditures of energy.
d.The sympathetic system relaxes blood vessels to counteract hypertension.
ANS: A
The sympathetic nervous system “gears up” the body for “fight or flight” situations with epinephrine that will raise the blood pressure (BP), reduce bowel motility, and energize the whole body to defend itself in a stressful situation. The parasympathetic system slows the heart rate after stress, supports deep sleep, and relaxes blood vessels.
PTS:1 DIF: Cognitive Level: Knowledge REF:475, Table 21-3
OBJ:2 (theory) TOP: Sympathetic Nervous System
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3.The nurse is assessing an 80-year-old patient. The nurse correctly attributes the slowed knee jerk reflex with which age- related change?
a.Diminished brain cells
b.Degeneration of myelin sheath
c.Weakened muscles
d.Irritation of nerve roots
ANS: B
In the peripheral nervous system (PNS), the motor nerve fibers and the myelin sheath degenerate with advancing age;
reflexes may become diminished or absent with advanced age. PTS:1DIF: Cognitive Level: Comprehension REF:484
OBJ:2 (theory) TOP: PNS: Diminished Reflexes
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4.A student nurse questions the nurse about the difference between a quadriplegic and a tetraplegic patient. Which statement correctly describes tetraplegia?
a.Tetraplegic patients are capable of fewer fine motor movements.
b.Tetraplegic patients can experience pain in paralyzed parts.
c.Tetraplegic patients are more easily rehabilitated.
d.Tetraplegia is the newer term for the old term quadriplegia. ANS: D
Tetraplegia is the newer term for the old term quadriplegia.
PTS:1DIF: Cognitive Level: Knowledge REF:492
OBJ:1 (theory) TOP: Tetraplegia vs. Quadriplegia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5.The nurse is performing a neurologic assessment on a patient. Which action should the nurse take to adequately test the effectiveness for the hypoglossal nerve?
a.Ask the patient to touch the tip of the tongue to each cheek.
b.Check air movement through each nostril separately.
c.Ask the patient to wrinkle the forehead.
