NEUROLOGICAL EXAM QUESTIONS WITH COMPLETE
SOLUTIONS UPDATED
The nurse is assessing the motor function of an unconscious client. The nurse
should plan to use which technique to test the client's peripheral response to
pain?
1. Sternal rub
2. Nail bed pressure
3. Pressure on the orbital rim
4. Squeezing of the sternocleidomastoid muscle
2. Nail bed pressure
Motor testing in the unconscious client can be done only by testing response to painful
stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain
are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing
the clavicle or sternocleidomastoid muscle.
The nurse is caring for the client with increased intracranial pressure. The nurse
would note which trend in vital signs if the intracranial pressure is rising?
1. Increasing temperature, increasing pulse, increasing respirations, decreasing
blood pressure
2. Increasing temperature, decreasing pulse, decreasing respirations, increasing
blood pressure
3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing
blood pressure
4. Decreasing temperature, increasing pulse, decreasing respirations, increasing
blood pressure
,2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood
pressure
A change in vital signs may be a late sign of increased intracranial pressure. Trends
include increasing temperature and blood pressure and decreasing pulse and
respirations. Respiratory irregularities also may occur.
A client recovering from a head injury is participating in care. The nurse
determines that the client understands measures to prevent elevations in
intracranial pressure if the nurse observes the client doing which activity?
1. Blowing the nose
2. Isometric exercises
3. Coughing vigorously
4. Exhaling during repositioning
4. Exhaling during repositioning
Activities that increase intrathoracic and intraabdominal pressures cause an indirect
elevation of the intracranial pressure. Some of these activities include isometric
exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling
during activities such as repositioning or pulling up in bed, opens the glottis, which
prevents intrathoracic pressure from rising.
A client has clear fluid leaking from the nose following a basilar skull fracture.
Which finding would alert the nurse that cerebrospinal fluid is present?
1. Fluid is clear and tests negative for glucose.
2. Fluid is grossly bloody in appearance and has a pH of 6.
3. Fluid clumps together on the dressing and has a pH of 7.
4. Fluid separates into concentric rings and tests positive for glucose.
4. Fluid separates into concentric rings and tests positive for glucose.
Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar
,skull fracture. CSF can be distinguished from other body fluids because the drainage
will separate into bloody and yellow concentric rings on dressing material, called a halo
sign. The fluid also tests positive for glucose.
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia.
The nurse should avoid which measure to minimize the risk of occurrence?
1. Strict adherence to a bowel retraining program
2. Keeping the linen wrinkle-free under the client
3. Preventing unnecessary pressure on the lower limbs
4. Limiting bladder catheterization to once every 12 hours
4. Limiting bladder catheterization to once every 12 hours
The most frequent cause of autonomic dysreflexia is a distended bladder. Straight
catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too
infrequent), and Foley catheters should be checked frequently to prevent kinks in the
tubing. Constipation and fecal impaction are other causes, so maintaining bowel
regularity is important. Other causes include stimulation of the skin from tactile, thermal,
or painful stimuli. The nurse administers care to minimize risk in these areas.
The nurse is evaluating the neurological signs of a client in spinal shock
following spinal cord injury. Which observation indicates that spinal shock
persists?
1. Hyperreflexia
2. Positive reflexes
3. Flaccid paralysis
4. Reflex emptying of the bladder
3. Flaccid paralysis
Resolution of spinal shock is occurring when there is return of reflexes (especially
flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and
reflex emptying of the bladder.
, The nurse is caring for a client who begins to experience seizure activity while in
bed. Which action by the nurse is contraindicated?
1. Loosening restrictive clothing
2. Restraining the client's limbs
3. Removing the pillow and raising padded side rails
4. Positioning the client to the side, if possible, with the head flexed forward
2. Restraining the client's limbs
Nursing actions during a seizure include providing for privacy, loosening restrictive
clothing, removing the pillow and raising padded side rails in the bed, and placing the
client on one side with the head flexed forward, if possible, to allow the tongue to fall
forward and facilitate drainage. The limbs are never restrained because the strong
muscle contractions could cause the client harm. If the client is not in bed when seizure
activity begins, the nurse lowers the client to the floor, if possible, protects the head
from injury, and moves furniture that may injure the client.
The nurse is assigned to care for a client with complete right-sided hemiparesis.
Which characteristics are associated with this condition? Select all that apply.
1. The client is aphasic.
2. The client has weakness in the face and tongue.
3. The client has weakness on the right side of the body.
4. The client has complete bilateral paralysis of the arms and legs.
5. The client has lost the ability to move the right arm but is able to walk
independently.
6. The client has lost the ability to ambulate independently but is able to feed and
bathe himself or herself without assistance.
1. The client is aphasic.
2. The client has weakness in the face and tongue.
3. The client has weakness on the right side of the body.
SOLUTIONS UPDATED
The nurse is assessing the motor function of an unconscious client. The nurse
should plan to use which technique to test the client's peripheral response to
pain?
1. Sternal rub
2. Nail bed pressure
3. Pressure on the orbital rim
4. Squeezing of the sternocleidomastoid muscle
2. Nail bed pressure
Motor testing in the unconscious client can be done only by testing response to painful
stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain
are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing
the clavicle or sternocleidomastoid muscle.
The nurse is caring for the client with increased intracranial pressure. The nurse
would note which trend in vital signs if the intracranial pressure is rising?
1. Increasing temperature, increasing pulse, increasing respirations, decreasing
blood pressure
2. Increasing temperature, decreasing pulse, decreasing respirations, increasing
blood pressure
3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing
blood pressure
4. Decreasing temperature, increasing pulse, decreasing respirations, increasing
blood pressure
,2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood
pressure
A change in vital signs may be a late sign of increased intracranial pressure. Trends
include increasing temperature and blood pressure and decreasing pulse and
respirations. Respiratory irregularities also may occur.
A client recovering from a head injury is participating in care. The nurse
determines that the client understands measures to prevent elevations in
intracranial pressure if the nurse observes the client doing which activity?
1. Blowing the nose
2. Isometric exercises
3. Coughing vigorously
4. Exhaling during repositioning
4. Exhaling during repositioning
Activities that increase intrathoracic and intraabdominal pressures cause an indirect
elevation of the intracranial pressure. Some of these activities include isometric
exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling
during activities such as repositioning or pulling up in bed, opens the glottis, which
prevents intrathoracic pressure from rising.
A client has clear fluid leaking from the nose following a basilar skull fracture.
Which finding would alert the nurse that cerebrospinal fluid is present?
1. Fluid is clear and tests negative for glucose.
2. Fluid is grossly bloody in appearance and has a pH of 6.
3. Fluid clumps together on the dressing and has a pH of 7.
4. Fluid separates into concentric rings and tests positive for glucose.
4. Fluid separates into concentric rings and tests positive for glucose.
Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar
,skull fracture. CSF can be distinguished from other body fluids because the drainage
will separate into bloody and yellow concentric rings on dressing material, called a halo
sign. The fluid also tests positive for glucose.
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia.
The nurse should avoid which measure to minimize the risk of occurrence?
1. Strict adherence to a bowel retraining program
2. Keeping the linen wrinkle-free under the client
3. Preventing unnecessary pressure on the lower limbs
4. Limiting bladder catheterization to once every 12 hours
4. Limiting bladder catheterization to once every 12 hours
The most frequent cause of autonomic dysreflexia is a distended bladder. Straight
catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too
infrequent), and Foley catheters should be checked frequently to prevent kinks in the
tubing. Constipation and fecal impaction are other causes, so maintaining bowel
regularity is important. Other causes include stimulation of the skin from tactile, thermal,
or painful stimuli. The nurse administers care to minimize risk in these areas.
The nurse is evaluating the neurological signs of a client in spinal shock
following spinal cord injury. Which observation indicates that spinal shock
persists?
1. Hyperreflexia
2. Positive reflexes
3. Flaccid paralysis
4. Reflex emptying of the bladder
3. Flaccid paralysis
Resolution of spinal shock is occurring when there is return of reflexes (especially
flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and
reflex emptying of the bladder.
, The nurse is caring for a client who begins to experience seizure activity while in
bed. Which action by the nurse is contraindicated?
1. Loosening restrictive clothing
2. Restraining the client's limbs
3. Removing the pillow and raising padded side rails
4. Positioning the client to the side, if possible, with the head flexed forward
2. Restraining the client's limbs
Nursing actions during a seizure include providing for privacy, loosening restrictive
clothing, removing the pillow and raising padded side rails in the bed, and placing the
client on one side with the head flexed forward, if possible, to allow the tongue to fall
forward and facilitate drainage. The limbs are never restrained because the strong
muscle contractions could cause the client harm. If the client is not in bed when seizure
activity begins, the nurse lowers the client to the floor, if possible, protects the head
from injury, and moves furniture that may injure the client.
The nurse is assigned to care for a client with complete right-sided hemiparesis.
Which characteristics are associated with this condition? Select all that apply.
1. The client is aphasic.
2. The client has weakness in the face and tongue.
3. The client has weakness on the right side of the body.
4. The client has complete bilateral paralysis of the arms and legs.
5. The client has lost the ability to move the right arm but is able to walk
independently.
6. The client has lost the ability to ambulate independently but is able to feed and
bathe himself or herself without assistance.
1. The client is aphasic.
2. The client has weakness in the face and tongue.
3. The client has weakness on the right side of the body.
