Chapter 21: Neurologic System Introduction
Linton: Medical-Surgical Nursing, 7th Edition
MULTIPLE CHOICE
1. A patient with a severe head injury begins to assume a posture of flexed upper
extremities, with plantarflexed lower extremities: What do these assessments indicate?
a. Increasing intracranial pressure (ICP) with decorticate posturing
b. Decreasing ICP with decerebrate posturing
c. Decreasing ICP with decorticate posturing
d. Increasing ICP with decerebrate posturing
ANS: A
Increasing pressure on the tissue above the midbrain results in abnormal flexion
(decorticate posturing):
DIF: Cognitive Level: Analysis REF: p: 366 OBJ: 4
TOP: Symptoms of Intracranial Pressure KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early
Detection of Disease
2. What should be immediately reported by the nurse caring for a 90-year-old patient with a
closed head injury?
a. Blood pressure change from 147/72 to 176/70-mm Hg
b. Respiration rate increase from 14 to 18 breaths/min
c. Slow pupillary reaction bilaterally
d. Temperature decrease from 100:2 F to 97:6 F
ANS: A
The widening pulse pressure is an indicator of increased ICP: Respirations and
temperature are returning to more normal levels: Older adults have a slowed pupillary
response as they age:
DIF: Cognitive Level: Analysis REF: p: 366 OBJ: 3
TOP: Nursing Care of Patient with Closed Head Injury
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early
Detection of Disease
3. Which assessment on a patient on mannitol therapy for cerebral edema indicates the
medication is effective in decreasing ICP?
a. Increased BP
b. Increased urinary output
, c. Decreased pulse
d. Widening pulse pressure
ANS: B
Mannitol is a hyperosmolar diuretic that draws fluid from brain tissue into the
bloodstream, which is then excreted by the kidneys: Decreasing pulse and widening
pulse pressure indicate increased ICP:
DIF: Cognitive Level: Comprehension REF: p: 367 OBJ: 5
TOP: Mannitol Therapy in Increased Intracranial Pressure (ICP)
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early
Detection of Disease
4. What should a nurse instruct a patient after a lumbar puncture to prevent a headache?
a. Lie flat:
b. Lie on left side:
c. Stay in semi-Fowler position:
d. Ambulate in the room with assistance:
ANS: A
Lying flat for a prescribed period will allow the loss of cerebrospinal fluid during the
procedure to replenish:
DIF: Cognitive Level: Application REF: p: 361 OBJ: 4
TOP: Lumbar Puncture Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
5. Which three symptoms are characteristic of Cushing triad associated with increased ICP?
a. Hypotension, tachycardia, and narrowing pulse pressure
b. Hypertension, tachycardia, and headache
c. Widening pulse pressure, headache, and seizure
d. Bradycardia, hypertension, and widening pulse pressure
ANS: D
Bradycardia, increasing BP, and widening pulse pressure are all signs of increased
ICP:
DIF: Cognitive Level: Knowledge REF: p: 366 OBJ: 3
TOP: Increased ICP: Cushing Triad KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early
Detection of Disease
6. How can the nurse help reduce ICP in caring for the patient after a craniotomy?
a. Keeping the patient flat in bed
b. Elevating the head of the bed 30 degrees
c. Closely monitoring the IV rate
, d. Turning the patient to the right side
ANS: B
Elevating the head of the bed at least 30 degrees helps reduce ICP:
DIF: Cognitive Level: Application REF: p: 365 OBJ: 4
TOP: Intervening for Increased ICP KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
7. A patient is stuporous but reacts by withdrawing from painful stimuli: What term is most
appropriate for this patient?
a. Comatose
b. Lethargic
c. Semicomatose
d. Somnolent
ANS: C
A stuporous patient who reacts to pain is semicomatose: The patient with no reaction
to pain is comatose:
DIF: Cognitive Level: Knowledge REF: p: 355 OBJ: 3
TOP: Neurologic Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8. Which describes the Babinski reflex?
a. Downward curl of the toes
b. Big toe bending upward
c. Spreading out of the toes
d. Pain in the big toe
ANS: A
Normal cortical function causes the toes to curl downward: Abnormal findings would
be the toes turning up and spreading:
DIF: Cognitive Level: Knowledge REF: p: 359 OBJ: 3
TOP: Neurologic Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
9. What should the nurse assess when a patient is scheduled for an angiogram?
a. Dizziness
b. Allergy to shrimp
c. Increased BP
d. Irregular heartbeat
ANS: B
Allergy to shrimp and other shellfish also indicates a probable allergy to contrast
, medium:
DIF: Cognitive Level: Application REF: p: 361 OBJ: 4
TOP: Angiogram Preassessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection
Control
10. To what does the neural synapse refer?
a. Length of time it takes for afferent neurons to carry impulses to the central
nervous system (CNS)
b. Length of time it takes for efferent neurons to carry impulses to the motor neurons
c. Space between the axons and the dendrites of a neuron
d. Space between the axons of one neuron and the dendrites of the next
ANS: D
Smooth, coordinated transmission must travel from one neuron to another across the
neural synapse:
DIF: Cognitive Level: Knowledge REF: p: 350 OBJ: 1
TOP: Anatomy and Physiology of the Central Nervous System (CNS)
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. An older adult patient is experiencing extreme stress related to an admission to the
hospital: What should the nurse expect the patient to demonstrate?
a. Decreased heart rate
b. Decreased blood pressure (BP)
c. Irregular respiration
d. Dilation of the pupils
ANS: D
Stress stimulates the fight-or-flight reaction with the release of epinephrine and
norepinephrine, which causes increased heart rate and BP, reduced peristalsis, and
pupil dilation:
DIF: Cognitive Level: Comprehension REF: p: 351 OBJ: 4
TOP: Effects of Sympathetic Nervous System
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12. Which neurologic finding would be considered abnormal in an 88-year-old patient?
a. Slow papillary response to light
b. Jerky eye movements
c. Dizziness and problems with balance
d. Absence of the Achilles tendon jerk
ANS: C
Linton: Medical-Surgical Nursing, 7th Edition
MULTIPLE CHOICE
1. A patient with a severe head injury begins to assume a posture of flexed upper
extremities, with plantarflexed lower extremities: What do these assessments indicate?
a. Increasing intracranial pressure (ICP) with decorticate posturing
b. Decreasing ICP with decerebrate posturing
c. Decreasing ICP with decorticate posturing
d. Increasing ICP with decerebrate posturing
ANS: A
Increasing pressure on the tissue above the midbrain results in abnormal flexion
(decorticate posturing):
DIF: Cognitive Level: Analysis REF: p: 366 OBJ: 4
TOP: Symptoms of Intracranial Pressure KEY: Nursing Process Step:
Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early
Detection of Disease
2. What should be immediately reported by the nurse caring for a 90-year-old patient with a
closed head injury?
a. Blood pressure change from 147/72 to 176/70-mm Hg
b. Respiration rate increase from 14 to 18 breaths/min
c. Slow pupillary reaction bilaterally
d. Temperature decrease from 100:2 F to 97:6 F
ANS: A
The widening pulse pressure is an indicator of increased ICP: Respirations and
temperature are returning to more normal levels: Older adults have a slowed pupillary
response as they age:
DIF: Cognitive Level: Analysis REF: p: 366 OBJ: 3
TOP: Nursing Care of Patient with Closed Head Injury
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early
Detection of Disease
3. Which assessment on a patient on mannitol therapy for cerebral edema indicates the
medication is effective in decreasing ICP?
a. Increased BP
b. Increased urinary output
, c. Decreased pulse
d. Widening pulse pressure
ANS: B
Mannitol is a hyperosmolar diuretic that draws fluid from brain tissue into the
bloodstream, which is then excreted by the kidneys: Decreasing pulse and widening
pulse pressure indicate increased ICP:
DIF: Cognitive Level: Comprehension REF: p: 367 OBJ: 5
TOP: Mannitol Therapy in Increased Intracranial Pressure (ICP)
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early
Detection of Disease
4. What should a nurse instruct a patient after a lumbar puncture to prevent a headache?
a. Lie flat:
b. Lie on left side:
c. Stay in semi-Fowler position:
d. Ambulate in the room with assistance:
ANS: A
Lying flat for a prescribed period will allow the loss of cerebrospinal fluid during the
procedure to replenish:
DIF: Cognitive Level: Application REF: p: 361 OBJ: 4
TOP: Lumbar Puncture Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
5. Which three symptoms are characteristic of Cushing triad associated with increased ICP?
a. Hypotension, tachycardia, and narrowing pulse pressure
b. Hypertension, tachycardia, and headache
c. Widening pulse pressure, headache, and seizure
d. Bradycardia, hypertension, and widening pulse pressure
ANS: D
Bradycardia, increasing BP, and widening pulse pressure are all signs of increased
ICP:
DIF: Cognitive Level: Knowledge REF: p: 366 OBJ: 3
TOP: Increased ICP: Cushing Triad KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early
Detection of Disease
6. How can the nurse help reduce ICP in caring for the patient after a craniotomy?
a. Keeping the patient flat in bed
b. Elevating the head of the bed 30 degrees
c. Closely monitoring the IV rate
, d. Turning the patient to the right side
ANS: B
Elevating the head of the bed at least 30 degrees helps reduce ICP:
DIF: Cognitive Level: Application REF: p: 365 OBJ: 4
TOP: Intervening for Increased ICP KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
7. A patient is stuporous but reacts by withdrawing from painful stimuli: What term is most
appropriate for this patient?
a. Comatose
b. Lethargic
c. Semicomatose
d. Somnolent
ANS: C
A stuporous patient who reacts to pain is semicomatose: The patient with no reaction
to pain is comatose:
DIF: Cognitive Level: Knowledge REF: p: 355 OBJ: 3
TOP: Neurologic Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8. Which describes the Babinski reflex?
a. Downward curl of the toes
b. Big toe bending upward
c. Spreading out of the toes
d. Pain in the big toe
ANS: A
Normal cortical function causes the toes to curl downward: Abnormal findings would
be the toes turning up and spreading:
DIF: Cognitive Level: Knowledge REF: p: 359 OBJ: 3
TOP: Neurologic Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
9. What should the nurse assess when a patient is scheduled for an angiogram?
a. Dizziness
b. Allergy to shrimp
c. Increased BP
d. Irregular heartbeat
ANS: B
Allergy to shrimp and other shellfish also indicates a probable allergy to contrast
, medium:
DIF: Cognitive Level: Application REF: p: 361 OBJ: 4
TOP: Angiogram Preassessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection
Control
10. To what does the neural synapse refer?
a. Length of time it takes for afferent neurons to carry impulses to the central
nervous system (CNS)
b. Length of time it takes for efferent neurons to carry impulses to the motor neurons
c. Space between the axons and the dendrites of a neuron
d. Space between the axons of one neuron and the dendrites of the next
ANS: D
Smooth, coordinated transmission must travel from one neuron to another across the
neural synapse:
DIF: Cognitive Level: Knowledge REF: p: 350 OBJ: 1
TOP: Anatomy and Physiology of the Central Nervous System (CNS)
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. An older adult patient is experiencing extreme stress related to an admission to the
hospital: What should the nurse expect the patient to demonstrate?
a. Decreased heart rate
b. Decreased blood pressure (BP)
c. Irregular respiration
d. Dilation of the pupils
ANS: D
Stress stimulates the fight-or-flight reaction with the release of epinephrine and
norepinephrine, which causes increased heart rate and BP, reduced peristalsis, and
pupil dilation:
DIF: Cognitive Level: Comprehension REF: p: 351 OBJ: 4
TOP: Effects of Sympathetic Nervous System
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12. Which neurologic finding would be considered abnormal in an 88-year-old patient?
a. Slow papillary response to light
b. Jerky eye movements
c. Dizziness and problems with balance
d. Absence of the Achilles tendon jerk
ANS: C
