When admitting an acutely confused patient with a head injury, which action would the nurse
a. Ask family members about the patient’s health history.
b. Ask leading questions to assist in obtaining health data.
c. Wait until the patient is better oriented to ask questions.
d. Obtain only the physiologic neurologic assessment data.
A
Which finding would the nurse expect when assessing the legs of a patient who has a lower
motor neuron lesion?
a. Spasticity
b. Flaccidity
c. Impaired sensation
d. Hyperactive reflexes
B
Which item would the nurse include in a focused assessment of a patient’s left posterior
temporal lobe functions?
a. Sensation on the left side of the body
b. Reasoning and problem-solving ability
c. Ability to understand written and oral language
d. Voluntary movements on the right side of the body
C
How would the nurse assess the patient’s trigeminal and facial nerve function (CNs V and
VID?
a. Check for unilateral eyelid droop.
b. Shine a light into the patient’s pupil.
c. Touch a cotton wisp strand to the cornea.
d. Have the patient read a magazine or book.
C
Which action would the nurse include in the plan of care for a patient with impaired function
of the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)?
a. Assist to stand and ambulate.
b. Withhold oral fluids and food.
c. Insert an oropharyngeal airway.
d. Apply artificial tears every hour.
B
An unconscious patient has just arrived in the emergency department with a head injury caused by a motorcycle crash. Which planned intervention by the health care provider would
the nurse question?
a. Obtain x-rays of the skull and spine.
b. Prepare the patient for lumbar puncture.
c.Send for computed tomography (CT) scan.
d. Perform neurologic checks every 15 minutes.
B
A patient with suspected meningitis is scheduled for a lumbar puncture. What action would the nurse take before the procedure?
a. Enforce NPO status for 4 hours.
b. Transfer the patient to radiology.
c. Administer a sedative medication.
d. Help the patient to a lateral position.
D
During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurse’s directions to move his hands and feet. Which condition would the nurse suspect as a likely cause of these findings?
a. Cerebellar injury
b. A brainstem lesion
c. Frontal lobe damage
d. A temporal lobe lesion
C
A patient has a tumor in the cerebellum. Which goal would the nurse use to focus the plan of care?
a.Prevent falls.
b. Stabilize mood.
c. Avoid aspiration.
d. Improve memory.
A
Which problem would the nurse expect for a patient who has a positive Romberg test result?
a. Pain
b. Falls
c. Aphasia
d. Confusion
B
Which test would the nurse anticipate discussing with a patient who has a possible seizure disorder?
a. Cerebral angiography
b. Evoked potential studies
c.Electromyography (EMG)
d. Electroencephalography (EEG)
D
Which equipment would the nurse obtain to assess vibration sense in a patient with diabetes who has peripheral nerve dysfunction?
a. Sharp pin
b. Tuning fork
c. Reflex hammer
d. Calibrated compass
B
Which information about a 76-yr-old patient would the nurse identify as uncharacteristic of normal aging?
a. Triceps reflex response graded at 1/5
b.Unintended weight loss of 15 pounds
c. Patient report of chronic difficulty in falling asleep
d. 10 mm Hg orthostatic drop in systolic blood pressure
B
The charge nurse is observing a new nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action by the new nurse indicates the need for further
teaching about neurologic assessment?
a. Tests for light touch before testing for pain.
b. Has the patient close the eyes during testing.
c.Asks the patient if the instrument feels sharp.
d.Uses an irregular pattern to test for intact touch.
C
Which cerebrospinal fluid analysis result would the nurse recognize as abnormal and communicate to the health care provider?
a. Specific gravity of 1.007
b.Protein of 65 mg/dL (0.65 g/L)
c. Glucose of 45 mg/dL (1.7 mmol/L)
d. White blood cell (WBC) count of 4 cells/µL
B
A 39-yr-old patient with a suspected herniated intervertebral disc is scheduled for a myelogram. Which information communicated by the nurse to the health care provider before
the procedure would change the procedural plans?
a. The patient is anxious about the test results.
b. The patient reports a previous allergy to shellfish.
c.The patient has back pain when lying flat for more than 4 hours.
d. The patient drank apple juice 4 hours before the scheduled procedure.
B
Which nursing assessment would the nurse consider the priority for a patient being admitted with a brainstem infarction?
a. Pupil reaction
b. Respiratory rate
c.Reflex reaction time
d. Level of consciousness
B
Which hospitalized patient would the nurse assess first?
a. A patient with a transient ischemic attack (TIA) returning from carotid duplex studies
b. A patient with a brain tumor who has just arrived on the unit after cerebral angiography
c. A patient with a seizure disorder who has just completed an electroencephalogram
d. A patient prepared for a lumbar puncture whose health care provider is waiting for assistance
B
Which assessments would the nurse make to monitor a patient’s cerebellar function? (Select all that apply.)
a.Test for graphesthesia.
b.Observe arm swing with gait.
c.Perform the finger-to-nose test.
d.Assess heat and cold sensation
e. Measure strength against resistance.
B,C
Which nursing actions would be included in the plan of care for a patient after cerebral angiography? (Select all that apply.)
a. Monitor for photophobia.
b. Observe for bleeding at the puncture site.
c.Keep patient NPO until gag reflex returns
d. Check pulse and blood pressure frequently.
e.Assess orientation to person, place, and time.
B,D,E
