NUR 425 Exam 1 Study Guide. Davis
Advantage Ch. 35, 36 & 39
Responsible for voluntary motor movement, Broca's speech, personality, and behavior.
- answerFrontal lobe
Primarily responsible for vision. - answerOccipital lobe
Responsible for sensory input and integration and spatial relationships. - answerParietal
lobe
Responsible for auditory sensation and perception, memory, and Wernicke's speech
center. - answerTemporal lobe
The nurse recognizes that patients with major changes in personality most likely have
damage in which lobe of the brain? - answerFrontal
The nurse correlates which responses as associated with the sympathetic nervous
system? (SATA)
A. Increased heart rate
B. Decreased respiratory rate
C. Increase in peristalsis
D. Dilated bronchioles
E. Decreased heart rate - answerAnswer: A and D
Rationale:
The sympathetic nervous system increases RR (dilates bronchi) and HR. It inhibits
peristalsis of the GI tract and dilates pupils.
The parasympathetic nervous system causes decreased heart
rate and respiratory rate, increases peristalsis of the GI tract, and constricts pupils.
A nurse is performing the initial interview of a patient presenting to the clinic because of
neurological complaints. Which actions by the nurse are appropriate? (SATA)
A. Assessment of physical appearance
B. Comprehensive medication list review
C. Reassurance that all will be okay
D. Review of alcohol and drug use
E. Review of risks - answerAnswer: A, B, and D
,Rationale: The nurse should not provide potentially false reassurance all will be okay or
use this opportunity to teach regarding the dangers of alcohol use.
A patient is scheduled for an emergency CT scan because of clinical manifestations of a
CVA/stroke. The nurse recognizes which statement as true about the findings of the CT
scan?
A. Thrombolytics are contraindicated if the scan identifies a bleed.
B. Thrombolytics are indicated if the scan is positive for a bleed.
C. Thrombolytics are contraindicated if the scan identifies an occlusion.
D. Thrombolytics are indicated if the scan identifies a bleed. - answerAnswer: A
Rationale: Thrombolytics are clot busters. If the patient
has had a hemorrhagic stroke, thrombolytics will cause additional bleeding. If the scan
is negative for a bleed, the patient may receive a thrombolytic to dissolve the clot if
there are no other contraindications such as use of anticoagulants.
The nurse correlates which clinical manifestations to age-related changes of the
nervous system? (SATA)
A. Decreased visual acuity
B. Increased pain sensation
C. Balance problems
D. Dementia
E. Decreased pain sensation - answerAnswer: A, C, and E
Rationale: Changes in the aged patient include decreased vision, balance and gait
problems, and decreased pain sensation. Dementia should not be considered a normal
part of aging—other causes should be ruled out.
The nurse understands maintaining good head and neck alignment is an important
component of managing increased intracranial pressure because
venous drainage from the brain occurs via which part of the vascular system?
A. Internal carotid arteries
B. External carotid arteries
C. Internal jugular veins
D. External jugular veins - answerAnswer: C
Rationale: The internal and external carotids are arteries and bring blood flow to the
brain. The internal jugular veins are the primary means of draining blood from the brain.
During what part of the neurological assessment is vision and hearing assessed? -
answerCranial nerve assessment
, What is an assessment tool used to assess wakefulness and arousal state? -
answerGlasgow Coma Scale
If an upper motor neuron lesion, MS, or drug/alcohol problems were suspected in a
client what sign would the nurse assess for? - answerBabinski reflex
After a lumbar puncture, the nurse asks the patient to lay flat for several hours. This
helps prevent which post-procedure complication?
A. Hypertension
B. Bleeding
C. Headache
D. Seizure - answerAnswer: C
Rationale: Sitting up after LP may result in a CSF leak, which may cause a headache.
Which assessment data does the nurse recognize as the most sensitive indicator of
increased ICP?
A. Pupillary
B. Respiratory
C. Level of consciousness
D. Cranial nerves - answerAnswer: C
Rationale: Change in LOC is the earliest sign of ICP and should be reported
immediately to the healthcare provider. There may be changes in pupillary reflexes,
cranial nerve function, and respiratory status, but they are all later signs.
A patient with a history of seizures experiences lip smacking and daydreams during a
seizure with no loss of consciousness. The nurse recognizes these clinical
manifestations as associated with which type of seizure? - answerAbsence seizure
Absence seizure signs/symptoms: - answerMay go unnoticed as the patient appears to
be inattentive or daydreaming
Usually last 5 to 10 seconds
Minimal muscle flaccidity, if any loss
May exhibit automatisms like lip smacking or excessive swallowing
Myoclonic seizure signs/symptoms: - answerPresent with no loss of consciousness
Include brief contractures of muscles (jerking) that may be symmetrical or asymmetrical
Advantage Ch. 35, 36 & 39
Responsible for voluntary motor movement, Broca's speech, personality, and behavior.
- answerFrontal lobe
Primarily responsible for vision. - answerOccipital lobe
Responsible for sensory input and integration and spatial relationships. - answerParietal
lobe
Responsible for auditory sensation and perception, memory, and Wernicke's speech
center. - answerTemporal lobe
The nurse recognizes that patients with major changes in personality most likely have
damage in which lobe of the brain? - answerFrontal
The nurse correlates which responses as associated with the sympathetic nervous
system? (SATA)
A. Increased heart rate
B. Decreased respiratory rate
C. Increase in peristalsis
D. Dilated bronchioles
E. Decreased heart rate - answerAnswer: A and D
Rationale:
The sympathetic nervous system increases RR (dilates bronchi) and HR. It inhibits
peristalsis of the GI tract and dilates pupils.
The parasympathetic nervous system causes decreased heart
rate and respiratory rate, increases peristalsis of the GI tract, and constricts pupils.
A nurse is performing the initial interview of a patient presenting to the clinic because of
neurological complaints. Which actions by the nurse are appropriate? (SATA)
A. Assessment of physical appearance
B. Comprehensive medication list review
C. Reassurance that all will be okay
D. Review of alcohol and drug use
E. Review of risks - answerAnswer: A, B, and D
,Rationale: The nurse should not provide potentially false reassurance all will be okay or
use this opportunity to teach regarding the dangers of alcohol use.
A patient is scheduled for an emergency CT scan because of clinical manifestations of a
CVA/stroke. The nurse recognizes which statement as true about the findings of the CT
scan?
A. Thrombolytics are contraindicated if the scan identifies a bleed.
B. Thrombolytics are indicated if the scan is positive for a bleed.
C. Thrombolytics are contraindicated if the scan identifies an occlusion.
D. Thrombolytics are indicated if the scan identifies a bleed. - answerAnswer: A
Rationale: Thrombolytics are clot busters. If the patient
has had a hemorrhagic stroke, thrombolytics will cause additional bleeding. If the scan
is negative for a bleed, the patient may receive a thrombolytic to dissolve the clot if
there are no other contraindications such as use of anticoagulants.
The nurse correlates which clinical manifestations to age-related changes of the
nervous system? (SATA)
A. Decreased visual acuity
B. Increased pain sensation
C. Balance problems
D. Dementia
E. Decreased pain sensation - answerAnswer: A, C, and E
Rationale: Changes in the aged patient include decreased vision, balance and gait
problems, and decreased pain sensation. Dementia should not be considered a normal
part of aging—other causes should be ruled out.
The nurse understands maintaining good head and neck alignment is an important
component of managing increased intracranial pressure because
venous drainage from the brain occurs via which part of the vascular system?
A. Internal carotid arteries
B. External carotid arteries
C. Internal jugular veins
D. External jugular veins - answerAnswer: C
Rationale: The internal and external carotids are arteries and bring blood flow to the
brain. The internal jugular veins are the primary means of draining blood from the brain.
During what part of the neurological assessment is vision and hearing assessed? -
answerCranial nerve assessment
, What is an assessment tool used to assess wakefulness and arousal state? -
answerGlasgow Coma Scale
If an upper motor neuron lesion, MS, or drug/alcohol problems were suspected in a
client what sign would the nurse assess for? - answerBabinski reflex
After a lumbar puncture, the nurse asks the patient to lay flat for several hours. This
helps prevent which post-procedure complication?
A. Hypertension
B. Bleeding
C. Headache
D. Seizure - answerAnswer: C
Rationale: Sitting up after LP may result in a CSF leak, which may cause a headache.
Which assessment data does the nurse recognize as the most sensitive indicator of
increased ICP?
A. Pupillary
B. Respiratory
C. Level of consciousness
D. Cranial nerves - answerAnswer: C
Rationale: Change in LOC is the earliest sign of ICP and should be reported
immediately to the healthcare provider. There may be changes in pupillary reflexes,
cranial nerve function, and respiratory status, but they are all later signs.
A patient with a history of seizures experiences lip smacking and daydreams during a
seizure with no loss of consciousness. The nurse recognizes these clinical
manifestations as associated with which type of seizure? - answerAbsence seizure
Absence seizure signs/symptoms: - answerMay go unnoticed as the patient appears to
be inattentive or daydreaming
Usually last 5 to 10 seconds
Minimal muscle flaccidity, if any loss
May exhibit automatisms like lip smacking or excessive swallowing
Myoclonic seizure signs/symptoms: - answerPresent with no loss of consciousness
Include brief contractures of muscles (jerking) that may be symmetrical or asymmetrical
