ne
sh
ne
la
tz
sh
Sp
NSG 2525 EXAM 4 QUESTION AND ne
la
sh
ANSWERS COMPLETE SOLUTION
Sp
ne
WITH RATIONELES
la
tz
sh
Sp
1. The nurse assesses for which condition or substance use in the client with clinical
ne
manifestations of depressed nervous cellular activity?
la
a. Caffeine
b. Acidosis
sh
Sp
c. Alkalosis
ne
d. Theophylline
la
Acidosis depresses the threshold of the nerve membrane so that less stimulus is
tz
needed to generate
sh
Sp
and transmit an impulse. Caffeine, alkalosis, and theophylline increase nervous cellular
ne
activity.
la
2. Which deficit will the nurse expect to find in a client who has experienced an injury to
sh
the frontal lobe of the brain?
Sp
a. Inability to interpret taste sensations
ne
b. Inability to interpret sound
la
c. Impaired judgment
tz
d. Impaired learning
sh
Sp
The frontal lobe is responsible for many functions, including judgment, reasoning,
ne
voluntary eye
la
movement, and motor functions.
sh
3. In providing discharge teaching related to cardiac medications to the client who has
Sp
ne
experienced damage to the left temporal lobe of the brain, the nurse includes which
information?
a
a. Use a larger print size for written materials.
tz
b. Ensure that the client is wearing glasses.
l
sh
Sp
c. Point out the color of the medication.
ne
d. Sit on the client's right side.
la
sh
Sp
la
Sp
, ne
sh
The temporal lobe contains the auditory center for sound interpretation. The client's
ne
hearing will la
be impaired in the left ear. The nurse should sit on the client's right side and speak to
tz
the right ear.
sh
Sp
ne
4. The nurse monitors for which clinical manifestations in the client receiving a
medication that stimulates the sympathetic division of the autonomic nervous system?
la
a. Decreased heart rate, decreased force of contraction
b. Increased heart rate, increased force of contraction
sh
Sp
c. Decreased heart rate, increased force of contraction
ne
d. Increased heart rate, decreased force of contraction
la
Stimulation of the sympathetic nervous system initiates the fightorflight response,
tz
increasing both the heart rate and force of contraction.
sh
Sp
ne
5. After performing a physical assessment on an older adult client, the nurse notes that
the client has a hypoactive response to a test of deep tendon reflexes. The nurse
la
incorporates which intervention into the client's plan of care?
sh
a. Assisting the client with ambulation
Sp
b. Elevating the client's lower extremities
ne
c. Placing elastic support hose on the client
la
d. Massaging the client's legs every 8 hours while he or she is awake
tz
sh
Sp
The older adult experiences certain neurologic changes associated with aging.
ne
Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and
la
coordination, predisposing the client to falls. The nurse or assistive personnel should
assist this client with ambulation to prevent injury.
sh
Sp
ne
6. Which instructions will the nurse include for the older adult client with diminished
touch sensation?
la
a. "Walk barefoot whenever possible."
tz
b. "Use very warm bath water to increase your circulation." sh
Sp
c. "Look at the placement of your feet when walking."
ne
d. "Put throw rugs at the foot of your bed for cushioning."
la
Older clients with decreased sensation are at risk of injury from the inability to sense
sh
changes in terrain when walking. The client is instructed to look at the placement of her
Sp
or his feet when walking to compensate for this loss. The client should also wear sturdy
ne
shoes for ambulation. Throw rugs can slip and increase fall risk. Bath water that is too
warm places the client at risk of
a
tz
thermal injury.
l
sh
Sp
7. A nurse is taking the history of a client with damage to the second and third cranial
ne
nerves. According to Gordon's Functional Health Patterns, which pattern disturbance is
la
this client experiencing?
sh
Sp
la
Sp
, ne
sh
a. Health Perception-Health Management Pattern
ne
b. Cognitive Perceptual Pattern la
c. Self Care Assistance Pattern
tz
d. Activity Exercise
sh
Pattern
Sp
ne
According to Gordon's Functional Health Patterns, alterations in sensory functions such
la
as hearing and vision reflect disturbances in the CognitivePerceptual Pattern.
sh
Sp
8. A client admitted the previous day for a suspected neurologic disorder becomes
ne
increasingly lethargic. With which condition does the nurse correlates this?
a. Sleep deprivation
la
b. Agerelated decline in mental processing
tz
c. Depression related to being hospitalized
sh
Sp
d. Decline in the client's central neurologic function
ne
A change in the client's level of consciousness (LOC) is the first indication of a decline
la
in central neurologic functioning.
sh
Sp
9. The nurse requests the client to perform which action for assessing remote memory?
ne
a. Make up a rhyme.
la
b. Name his or her date of birth.
tz
c. Repeat several unrelated words.
sh
d. Ask who brought the client to the clinic.
Sp
ne
Asking clients about certain facts from the past that can be verified assesses remote, or
la
longterm, memory
sh
Sp
10. Which technique will the nurse use to assess a client for pain sensation using a
ne
sharp or dull instrument?
a. Test first with eyes open, then with eyes closed.
la
b. Test for dull sensation first, followed by testing for sharp sensation.
tz
c. Test for sharp sensation first, followed by testing for dull sensation.
sh
Sp
d. Test for sharp and dull sensation randomly.
ne
The proper assessment technique for assessing pain sensation is to test the client for
la
sharp and dull sensation randomly to prevent the client from anticipating the type of
sh
stimulus that will follow.
Sp
ne
11. During a neurologic examination, the client demonstrates a positive Romberg's sign
with eyes closed, but not with eyes open. The nurse determines these findings to be
a
tz
indicative of which condition?
l
sh
a. Difficulty with proprioception
Sp
b. Peripheral motor disorder
ne
c. Cerebellar lesion
la
d. Pronator drift
sh
Sp
la
Sp
, ne
sh
ne
The client who sways with eyes closed (positive Romberg's sign) but not with eyes open
la
most likely has a disorder of proprioception and uses vision to compensate for it.
tz
sh
12. In assessing pain discrimination, the client has correctly identified, with eyes closed,
Sp
ne
a sharp sensation on the right hand when touched with a pin. How will the nurse then
proceed with the examination?
la
a. Touch the pin on the same area of the left hand.
b. Touch the pin on the right forearm.
sh
Sp
c. Touch the pin on the right upper arm.
ne
d. Touch the right hand with a drop of cold water.
la
If testing is begun on the hand and the client correctly identifies the pain stimulus, there
tz
is no need to test more proximal parts of that extremity because, if the distal tract is
sh
Sp
intact, so are the proximal areas. Temperature discrimination is not necessary because
ne
the same tract transmits both pain and temperature sensation.
la
13. On assessment of the right plantar reflexes of an adult client, a nurse notes that the
sh
client's response to this test is dorsiflexion of the great toe, with a fanning out of all the
Sp
other toes. Which is the nurse's next action after assessing this new finding?
ne
a. Relay this abnormal finding to other members of the health care team.
la
b. Anticipate the need for cerebral angiography to determine the cause.
tz
c. Examine the family history for a potential genetic disorder.
sh
d. Document the finding and continue the assessment.
Sp
ne
This finding is a positive Babinski reflex. In clients older than 2 years, a positive
la
Babinski reflex is considered abnormal and indicative of central nervous system
disease. The nurse should notify the physician and other members of the health care
sh
team because further investigation is warranted.
Sp
ne
14. The nurse monitors for which response when assessing the deep tendon reflexes of
la
a client with longstanding diabetes mellitus?
tz
a. Bilateral hypoactive reflexes of the knees and Achilles tendons sh
Sp
b. Bilateral hyperactive reflexes of the knees and Achilles tendons
ne
c. Asymmetric reflex response
d. Bilateral ankle clonus
la
sh
Longstanding diabetes mellitus causes peripheral neuropathy. Hypoactive responses or
Sp
no response to stimulation of deep tendon reflexes is one manifestation of diabetes
ne
induced peripheral neuropathy.
a
tz
15. During the neurologic assessment of a client, the nurse notes that the client's arms,
l
sh
wrists, and fingers have become flexed, and there is internal rotation and plantar flexion
Sp
of the legs. How does the nurse document these findings?
ne
a. Decorticate posturing
la
b. Decerebrate posturing
sh
Sp
la
Sp
sh
ne
la
tz
sh
Sp
NSG 2525 EXAM 4 QUESTION AND ne
la
sh
ANSWERS COMPLETE SOLUTION
Sp
ne
WITH RATIONELES
la
tz
sh
Sp
1. The nurse assesses for which condition or substance use in the client with clinical
ne
manifestations of depressed nervous cellular activity?
la
a. Caffeine
b. Acidosis
sh
Sp
c. Alkalosis
ne
d. Theophylline
la
Acidosis depresses the threshold of the nerve membrane so that less stimulus is
tz
needed to generate
sh
Sp
and transmit an impulse. Caffeine, alkalosis, and theophylline increase nervous cellular
ne
activity.
la
2. Which deficit will the nurse expect to find in a client who has experienced an injury to
sh
the frontal lobe of the brain?
Sp
a. Inability to interpret taste sensations
ne
b. Inability to interpret sound
la
c. Impaired judgment
tz
d. Impaired learning
sh
Sp
The frontal lobe is responsible for many functions, including judgment, reasoning,
ne
voluntary eye
la
movement, and motor functions.
sh
3. In providing discharge teaching related to cardiac medications to the client who has
Sp
ne
experienced damage to the left temporal lobe of the brain, the nurse includes which
information?
a
a. Use a larger print size for written materials.
tz
b. Ensure that the client is wearing glasses.
l
sh
Sp
c. Point out the color of the medication.
ne
d. Sit on the client's right side.
la
sh
Sp
la
Sp
, ne
sh
The temporal lobe contains the auditory center for sound interpretation. The client's
ne
hearing will la
be impaired in the left ear. The nurse should sit on the client's right side and speak to
tz
the right ear.
sh
Sp
ne
4. The nurse monitors for which clinical manifestations in the client receiving a
medication that stimulates the sympathetic division of the autonomic nervous system?
la
a. Decreased heart rate, decreased force of contraction
b. Increased heart rate, increased force of contraction
sh
Sp
c. Decreased heart rate, increased force of contraction
ne
d. Increased heart rate, decreased force of contraction
la
Stimulation of the sympathetic nervous system initiates the fightorflight response,
tz
increasing both the heart rate and force of contraction.
sh
Sp
ne
5. After performing a physical assessment on an older adult client, the nurse notes that
the client has a hypoactive response to a test of deep tendon reflexes. The nurse
la
incorporates which intervention into the client's plan of care?
sh
a. Assisting the client with ambulation
Sp
b. Elevating the client's lower extremities
ne
c. Placing elastic support hose on the client
la
d. Massaging the client's legs every 8 hours while he or she is awake
tz
sh
Sp
The older adult experiences certain neurologic changes associated with aging.
ne
Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and
la
coordination, predisposing the client to falls. The nurse or assistive personnel should
assist this client with ambulation to prevent injury.
sh
Sp
ne
6. Which instructions will the nurse include for the older adult client with diminished
touch sensation?
la
a. "Walk barefoot whenever possible."
tz
b. "Use very warm bath water to increase your circulation." sh
Sp
c. "Look at the placement of your feet when walking."
ne
d. "Put throw rugs at the foot of your bed for cushioning."
la
Older clients with decreased sensation are at risk of injury from the inability to sense
sh
changes in terrain when walking. The client is instructed to look at the placement of her
Sp
or his feet when walking to compensate for this loss. The client should also wear sturdy
ne
shoes for ambulation. Throw rugs can slip and increase fall risk. Bath water that is too
warm places the client at risk of
a
tz
thermal injury.
l
sh
Sp
7. A nurse is taking the history of a client with damage to the second and third cranial
ne
nerves. According to Gordon's Functional Health Patterns, which pattern disturbance is
la
this client experiencing?
sh
Sp
la
Sp
, ne
sh
a. Health Perception-Health Management Pattern
ne
b. Cognitive Perceptual Pattern la
c. Self Care Assistance Pattern
tz
d. Activity Exercise
sh
Pattern
Sp
ne
According to Gordon's Functional Health Patterns, alterations in sensory functions such
la
as hearing and vision reflect disturbances in the CognitivePerceptual Pattern.
sh
Sp
8. A client admitted the previous day for a suspected neurologic disorder becomes
ne
increasingly lethargic. With which condition does the nurse correlates this?
a. Sleep deprivation
la
b. Agerelated decline in mental processing
tz
c. Depression related to being hospitalized
sh
Sp
d. Decline in the client's central neurologic function
ne
A change in the client's level of consciousness (LOC) is the first indication of a decline
la
in central neurologic functioning.
sh
Sp
9. The nurse requests the client to perform which action for assessing remote memory?
ne
a. Make up a rhyme.
la
b. Name his or her date of birth.
tz
c. Repeat several unrelated words.
sh
d. Ask who brought the client to the clinic.
Sp
ne
Asking clients about certain facts from the past that can be verified assesses remote, or
la
longterm, memory
sh
Sp
10. Which technique will the nurse use to assess a client for pain sensation using a
ne
sharp or dull instrument?
a. Test first with eyes open, then with eyes closed.
la
b. Test for dull sensation first, followed by testing for sharp sensation.
tz
c. Test for sharp sensation first, followed by testing for dull sensation.
sh
Sp
d. Test for sharp and dull sensation randomly.
ne
The proper assessment technique for assessing pain sensation is to test the client for
la
sharp and dull sensation randomly to prevent the client from anticipating the type of
sh
stimulus that will follow.
Sp
ne
11. During a neurologic examination, the client demonstrates a positive Romberg's sign
with eyes closed, but not with eyes open. The nurse determines these findings to be
a
tz
indicative of which condition?
l
sh
a. Difficulty with proprioception
Sp
b. Peripheral motor disorder
ne
c. Cerebellar lesion
la
d. Pronator drift
sh
Sp
la
Sp
, ne
sh
ne
The client who sways with eyes closed (positive Romberg's sign) but not with eyes open
la
most likely has a disorder of proprioception and uses vision to compensate for it.
tz
sh
12. In assessing pain discrimination, the client has correctly identified, with eyes closed,
Sp
ne
a sharp sensation on the right hand when touched with a pin. How will the nurse then
proceed with the examination?
la
a. Touch the pin on the same area of the left hand.
b. Touch the pin on the right forearm.
sh
Sp
c. Touch the pin on the right upper arm.
ne
d. Touch the right hand with a drop of cold water.
la
If testing is begun on the hand and the client correctly identifies the pain stimulus, there
tz
is no need to test more proximal parts of that extremity because, if the distal tract is
sh
Sp
intact, so are the proximal areas. Temperature discrimination is not necessary because
ne
the same tract transmits both pain and temperature sensation.
la
13. On assessment of the right plantar reflexes of an adult client, a nurse notes that the
sh
client's response to this test is dorsiflexion of the great toe, with a fanning out of all the
Sp
other toes. Which is the nurse's next action after assessing this new finding?
ne
a. Relay this abnormal finding to other members of the health care team.
la
b. Anticipate the need for cerebral angiography to determine the cause.
tz
c. Examine the family history for a potential genetic disorder.
sh
d. Document the finding and continue the assessment.
Sp
ne
This finding is a positive Babinski reflex. In clients older than 2 years, a positive
la
Babinski reflex is considered abnormal and indicative of central nervous system
disease. The nurse should notify the physician and other members of the health care
sh
team because further investigation is warranted.
Sp
ne
14. The nurse monitors for which response when assessing the deep tendon reflexes of
la
a client with longstanding diabetes mellitus?
tz
a. Bilateral hypoactive reflexes of the knees and Achilles tendons sh
Sp
b. Bilateral hyperactive reflexes of the knees and Achilles tendons
ne
c. Asymmetric reflex response
d. Bilateral ankle clonus
la
sh
Longstanding diabetes mellitus causes peripheral neuropathy. Hypoactive responses or
Sp
no response to stimulation of deep tendon reflexes is one manifestation of diabetes
ne
induced peripheral neuropathy.
a
tz
15. During the neurologic assessment of a client, the nurse notes that the client's arms,
l
sh
wrists, and fingers have become flexed, and there is internal rotation and plantar flexion
Sp
of the legs. How does the nurse document these findings?
ne
a. Decorticate posturing
la
b. Decerebrate posturing
sh
Sp
la
Sp
