Assessing The Nervous System Exam Prep Ch.41 nan - Medical Surgical Nursing 7e | Test Bank by LeMone, Burke, Bauldoff by LeMone, Burke, Gerene Bauldoff. DOCX document preview.
LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno)
Chapter 41 Assessing the Nervous System
1) The nurse is preparing to assess a patient's cognitive function. What should the nurse include in this assessment?
1. Ability to smell items placed under the nose while eyes are closed
2. Orientation to time, place, and person, and ability to recall recent and past events
3. Ability to walk with a smooth, steady gait
4. Level of consciousness
Page Ref: 1534
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.
2) The nurse is preparing to assess a patient's cranial nerve XI (spinal accessory). What should the nurse ask the patient to complete this assessment?
1. Shrug the shoulders and turn the head against resistance.
2. Stick out the tongue and move it from side to side.
3. Taste foods and distinguish sweet from sour.
4. Smell items with one nostril blocked and identify them correctly.
Page Ref: 1535
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.
3) The nurse is preparing to assess a patient's neurologic system. What should the nurse do to assess sensory function?
1. Touch both sides of various parts of the body with a sharp and a dull object.
2. Have the patient distinguish which parts of the body are being touched.
3. Ask the patient to identify two areas of simultaneous pinpricks on the hand.
4. Write a number on the patient's hand and have him or her identify the number.
Page Ref: 1535
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.
4) The nurse wants to determine if a patient is experiencing tremors. When performing this assessment, for what should the nurse observe?
1. Shaking
2. Jerky movements
3. Rhythmic movements
4. Fasciculations
Page Ref: 1536
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.
5) A patient is exhibiting a lack of coordination, clumsy movements, and an unbalanced gait. What term should the nurse use when documenting these observations?
1. Flaccidity
2. Paralysis
3. Hemiparesis
4. Ataxia
Page Ref: 1536
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.
6) The nurse asks a patient to stand with the feet together and eyes closed. What must the nurse observe for the Romberg test to be considered normal?
1. Swaying from side to side
2. Minimal swaying for up to 20 seconds
3. Sufficient balance to hold completely still without swaying
4. Swaying to one side and loss of balance
Page Ref: 1536
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 2. Recognize normal findings of the nervous system collected during assessment and health promotion activities to support the health of this body system.
7) The nurse asks the patient to walk heel-to-toe, on the toes, and then on the heels. What function is the nurse assessing?
1. Cerebellar
2. Cerebral
3. Midbrain
4. Brainstem
Page Ref: 1536
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.
8) While assisting with a lumbar puncture, the nurse determines that a patient's cerebrospinal (CSF) fluid is normal. What did the nurse assess to make this clinical decision?
1. The CSF is yellow, without sediment.
2. The CSF is tinged with blood but has no sediment.
3. The CSF is clear and colorless.
4. The CSF is pink, without sediment.
Page Ref: 1525
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.1 Describe the anatomy, physiology, and functions of the nervous system and identify abnormal findings that may indicate impairments of the nervous system.
MNL Learning Outcome: 2. Recognize normal findings of the nervous system collected during assessment and health promotion activities to support the health of this body system.
9) The nurse is assessing a patient's muscle strength and movement. What should the nurse do when completing this assessment?
1. Grade the posterior tibial pulses.
2. Grade flaccidity.
3. Observe whether strength and movement are bilaterally equal and strong.
4. Ask the patient to walk normally in a heel-to-toe sequence.
Page Ref: 1536
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.
10) The patient has lower motor neuron injuries. What type of reflexes should the nurse expect to assess in this patient?
1. Decreased
2. Increased
3. Normal
4. Exaggerated
Page Ref: 1537
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.
11) A patient in the supine position with the head flexed to the chest is not experiencing any pain, resistance, or flexion of the hips or knees. What is the nurse assessing in this patient?
1. Doll's-eyes reflex
2. Brudzinski sign
3. Babinski reflex
4. Kernig sign
Page Ref: 1538
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.
12) The nurse is planning to assess an adult patient with a neurological problem for abnormal posturing. For what posture should the nurse specifically assess? Select all that apply.
1. Decorticate
2. Decerebrate
3. Circumduction
4. Festinating
5. Nystagmus
Page Ref: 1538
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.
13) A patient is suspected of having a neuromuscular disease. What neurological test helps to diagnose this type of health problem?
1. Single-photon emission computed tomography (SPECT)
2. Positron emission tomography (PET)
3. Magnetic resonance imaging (MRI)
4. Electromyogram (EMG)
Page Ref: 1540
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the nervous system.
14) A patient in the hospital critical care unit is being evaluated for brain death. What neurological test should the nurse expect to be prescribed for this patient?
1. Electroencephalogram (EEG)
2. Computed tomography (CT)
3. Evoked potentials
4. Electromyogram (EMG)
Page Ref: 1539
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the nervous system.
15) A patient is in the hospital with suspected intracerebral hemorrhage. Which neurologic test is most likely to be prescribed for this patient?
1. X-rays of the spine
2. Computed tomography (CT)
3. Evoked potentials
4. Electroencephalogram (EEG)
Page Ref: 1539
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the nervous system.
16) A victim who was thrown 50 feet in a motor vehicle crash experiences transient consciousness en route to the emergency department. What neurological tests should the nurse expect to be prescribed for this patient?
1. Magnetic resonance imaging (MRI) and computed tomography (CT)
2. Computed tomography (CT) and positron emission tomography (PET)
3. X-rays of the skull and spine and computed tomography (CT)
4. Computed tomography (CT)
Page Ref: 1539, 1540
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the nervous system.
17) The nurse suspects that an older patient is experiencing age-related changes of a decreased number of brain cells, decreased cerebral blood flow, and decreased metabolism. How would these changes affect the plan of care for the patient at home? Select all that apply.
1. Will be distracted after a few minutes on the task
2. Will not be open to learning to perform a dressing change
3. Will be less reliable at completing self-care activities
4. Will have delayed responses if too many stimuli occur
5. Will have an increased risk for falls
Page Ref: 1541
Cognitive Level: Analyzing
Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 41.3 Differentiate considerations for assessing the nervous systems of older adults and veterans.
MNL Learning Outcome: 2. Recognize normal findings of the nervous system collected during assessment and health promotion activities to support the health of this body system.
18) The nurse is conducting a seminar on Alzheimer disease (AD) with a group of community members. How should the nurse describe this health problem? Select all that apply.
1. The incidence of AD increases with age.
2. AD tends to run in families.
3. AD is more common in men.
4. AD is caused by a virus.
5. AD is caused by environmental contaminants.
Page Ref: 1532
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Aging Process
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.
19) A patient is being treated for a common neurological disease that is characterized by abnormal cell firing in the brain. For what should the nurse assess in this patient?
1. Loss of consciousness
2. Seizures
3. Decerebrate posturing
4. Headache
Page Ref: 1532
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.
20) The family of a patient recovering from a stroke asks what damage to "Broca's area" means. Which is the best response by the nurse?
1. "The way you communicate will have to change."
2. "You'll have to speak very loudly when you talk."
3. "Make sure there are no obstacles in the room, because sight will be a problem."
4. "Perhaps you would like to learn how to provide range-of-motion exercises."
Page Ref: 1525
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation
Learning Outcome: 41.1 Describe the anatomy, physiology, and functions of the nervous system and identify abnormal findings that may indicate impairments of the nervous system.
MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.
21) A patient experiencing extreme emotional stress is observed to be exhibiting both tachycardia and tachypnea. Which component of the patient's nervous system is responsible for normalizing the patient's response?
1. Central
2. Peripheral
3. Sympathetic
4. Parasympathetic
Page Ref: 1531
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.1 Describe the anatomy, physiology, and functions of the nervous system and identify abnormal findings that may indicate impairments of the nervous system.
MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.
22) During a health history, the nurse plans to assess the functioning of a patient's central nervous system (CNS). Which question should the nurse ask to assess this function?
1. "Do you get dizzy when moving from a sitting to standing position?"
2. "Do you have difficulty adjusting to changes in temperature?"
3. "Do you have difficulty falling asleep in the evening?"
4. "Have you had any weight loss?"
Page Ref: 1525
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.1 Describe the anatomy, physiology, and functions of the nervous system and identify abnormal findings that may indicate impairments of the nervous system.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.
23) A patient reports hearing noises when alone in a quiet room. What action should the nurse take?
1. Make sure the patient is referred to a psychiatrist.
2. Document that the patient has a mental illness.
3. Ask if the patient experiences any visual disturbances.
4. Explain to the patient that this is not unusual.
Page Ref: 1534
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.
24) The nurse suspects a patient may be experiencing dysfunction related to the acoustic nerve (CN VIII). Which action should the nurse take to minimize the patient's risk for injury? Select all that apply.
1. Identifying the patient's fall risk category
2. Assessing the patient's gag reflex prior to offering food or liquids
3. Assisting the patient with bedside sitting or toileting
4. Assessing the patient's vision using a Snellen chart
5. Placing a red "falls risk" bracelet on the patient's arm
Page Ref: 1530
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality & Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 41.1 Describe the anatomy, physiology, and functions of the nervous system and identify abnormal findings that may indicate impairments of the nervous system.
MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.
25) During an assessment, a patient's tongue deviates markedly to the right side. What is the patient most likely exhibiting?
1. Abnormal hypoglossal nerve response
2. First cranial nerve (CN I) damage
3. Sluggish oculomotor response
4. Absence of the Homans sign
Page Ref: 1535
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.
26) A patient in the emergency department (ED) has a Glasgow Coma Scale (GCS) score of 8. Which is the most appropriate action by the nurse?
1. Treat the patient's pain.
2. Assess the patient's airway, breathing, and circulation.
3. Obtain a complete history from the patient.
4. Triage the patient with the other ED patients.
Page Ref: 1533
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.
27) The meal tray for a patient with damage to the glossopharyngeal nerve (CN IX) has been delivered. What action should the nurse take first?
1. Tell the patient what food is on the tray.
2. Assess the patient's ability to swallow.
3. Speak loudly and make eye contact with the patient.
4. Assist the patient in identifying where items are on the tray.
Page Ref: 1535
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.
28) The nurse is conducting a health history with a patient exhibiting signs of Parkinson disease. Which question should the nurse ask the patient?
1. "Do you recall if any of your relatives had difficulty holding on to things with their hands?"
2. "Do you remember what you ate for breakfast this morning?"
3. "Is it painful to flex your chin to your chest?"
4. "Did your muscle weakness first occur in your arms or in your legs?"
Page Ref: 1532
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.
29) A patient's reflexes are documented as being 3+. How should the nurse interpret this finding?
1. The patient's reflexes are weaker than normal.
2. The patient's reflexes are normal.
3. The patient's reflexes are stronger than normal.
4. The patient's reflexes are hyperactive.
Page Ref: 1537
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.
30) A patient with a fine tremor in the right hand and arm asks what a primary essential tremor means. What is the best response by the nurse?
1. "Essential tremor occurs 5 to 10 years before the onset of Parkinson disease."
2. "When essential tremor is a primary disorder, it is usually inherited."
3. "Essential tremor is very rare. It affects only about 100,000 people."
4. "People with essential tremor often go on to develop cardiovascular disease."
Page Ref: 1532
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.
31) The nurse asks a patient who experienced a cerebral vascular accident (CVA) to complete the heel-to-shin test. What is the nurse testing for with this technique?
1. Ataxia
2. Graphesthesia
3. Coordination
4. Spasticity
Page Ref: 1537
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.
32) A patient is prescribed a medication that affects the beta1- and beta2-receptors in the body. Which effect of this medication should the nurse expect to assess? Select all that apply.
1. Normal heart rate
2. Improved respiration
3. Lower blood pressure
4. Reduced muscle cramps
5. Increased blood glucose level
Page Ref: 1524
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.1 Describe the anatomy, physiology, and functions of the nervous system and identify abnormal findings that may indicate impairments of the nervous system.
MNL Learning Outcome: 2. Recognize normal findings of the nervous system collected during assessment and health promotion activities to support the health of this body system.
33) The nurse is concerned that a patient is experiencing sympathetic nervous system effects after a head injury. What did the nurse assess to make this clinical decision? Select all that apply.
1. Damp skin
2. Cold extremities
3. Heart rate 68 bpm
4. Deep, rapid respirations
5. Elevated blood pressure
Page Ref: 1529-1530
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.1 Describe the anatomy, physiology, and functions of the nervous system and identify abnormal findings that may indicate impairments of the nervous system.
MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.
34) During a health history, the nurse becomes concerned that a patient is at risk for a neurological problem because of occupational and social hazards. What finding caused the nurse to have this concern? Select all that apply.
1. The patient smokes 1 ppd of cigarettes.
2. The patient and spouse walk the family dog after dinner.
3. The patient works in a chemical plant that manufactures plastic.
4. The patient plays football with college friends every Saturday afternoon.
5. The patient rides a motorcycle in a state where headgear is not mandatory.
Page Ref: 1531-1532
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment.
MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.
35) A patient is being evaluated for disease of the lower motor neurons. Which assessment finding should the nurse identify as consistent with this health problem? Select all that apply.
1. Spasticity
2. Flaccidity
3. Steppage gait
4. Fasciculations
5. Muscle atrophy
Page Ref: 1528
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 41.1 Describe the anatomy, physiology, and functions of the nervous system and identify abnormal findings that may indicate impairments of the nervous system.
MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.
36) An older patient is diagnosed with a new onset of a seizure disorder. What should the nurse recall when planning care for this patient? Select all that apply.
1. Commonly caused by a stroke
2. Post-seizure manifestations will last longer
3. Complex partial seizures are the most common type
4. Commonly caused by arteriosclerosis of the cerebrovascular system
5. Anti-seizure medication is not as effective in controlling the seizures
Page Ref: 1541
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 41.3 Differentiate considerations for assessing the nervous systems of older adults and veterans.
MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.
37) The nurse is preparing a teaching tool to prevent injuries. What should the nurse include to prevent neurologic injuries due to trauma? Select all that apply.
1. Wear seat belts.
2. Practice vehicular safety.
3. Wear helmets when bicycling.
4. Have an annual eye examination.
5. Wear helmets when riding a motorcycle.
Page Ref: 1541
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 41.4 Summarize topics that nurses teach to promote healthy tissue integrity across the lifespan.
MNL Learning Outcome: 2. Recognize normal findings of the nervous system collected during assessment and health promotion activities to support the health of this body system.
38) A patient asks what can be done to prevent the development of a neurologic disorder like other family members have developed over the years. What should the nurse recommend to the patient? Select all that apply.
1. Obtain sufficient sleep.
2. Consume a healthy diet.
3. Consider genetic testing.
4. Engage in regular physical activity.
5. Have routine neurologic examinations.
Page Ref: 1541
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 41.4 Summarize topics that nurses teach to promote healthy tissue integrity across the lifespan.
MNL Learning Outcome: 2. Recognize normal findings of the nervous system collected during assessment and health promotion activities to support the health of this body system.
Document Information
Connected Book
Medical Surgical Nursing 7e | Test Bank by LeMone, Burke, Bauldoff
By LeMone, Burke, Gerene Bauldoff
Explore recommendations drawn directly from what you're reading
Chapter 39 Nursing Care Of Patients With Musculoskeletal Trauma
DOCX Ch. 39
Chapter 40 Nursing Care Of Patients With Musculoskeletal Disorders
DOCX Ch. 40
Chapter 41 Assessing The Nervous System
DOCX Ch. 41 Current
Chapter 42 Nursing Care Of Patients With Intracranial Disorders
DOCX Ch. 42
Chapter 43 Spine & CNS Disorder Care
DOCX Ch. 43