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Exam 23: Neurologic System

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Question 1

Multiple Choice

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The nurse is caring for a patient who has just had neurosurgery.To assess for increased intracranial pressure,what would the nurse include in the assessment?

A) Cranial nerves,motor function,and sensory function
B) Deep tendon reflexes,vital signs,and coordinated movements
C) Level of consciousness,motor function,pupillary response,and vital signs
D) Mental status,deep tendon reflexes,sensory function,and pupillary response

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Question 2

Multiple Choice

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The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor.With the reflex hammer,the nurse draws a light stroke up the lateral side of the sole of the foot and inward,across the ball of the foot.In response,the patient's toes fan out,and the big toe shows dorsiflexion.The nurse recognizes this as which of the following?

A) A negative Babinski's sign,which is normal for adults
B) A positive Babinski's sign,which is abnormal for adults
C) Clonus,a hyperactive response
D) The Achilles reflex,an expected response

Correct Answer

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B

Question 3

Multiple Choice

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The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination.When striking the Achilles and quadriceps,the nurse is unable to elicit a reflex.The nurse's next response should be to:

During an assessment of a 32-year-old patient with a recent head injury,the nurse notes that the patient responds to pain by extending,adducting,and internally rotating his arms.His palms pronate and his lower extremities extend as well with plantar flexion.Which of the following statements about these findings is accurate?

A 50-year-old woman is in the clinic for "weakness in my left arm and leg for the past week." The nurse will perform which type of neurologic examination?

The nurse knows that testing kinesthesia is a test of a person's:

In assessing a 70-year-old patient who has had a recent cerebrovascular accident,the nurse notes right-sided weakness.What might the nurse expect to find when testing his reflexes on the right side?

The nurse knows that which of the following scores would indicate that a patient is in a coma on the basis of the criteria of the Glasgow Coma Scale?

A 78-year-old man has a history of a cerebrovascular accident.The nurse notes that when he walks his left arm is immobile against the body with flexion of the shoulder,elbow,wrist and fingers and adduction of the shoulder.His left leg is stiff and extended and circumducts with each step.What type of gait disturbance is this individual experiencing?

A patient with lack of oxygen to his heart will have pain in his chest and also possibly the shoulder,arms,or jaw.Which of the following best explains why this occurs?

To assess the head control of a 4-month-old infant,the nurse lifts the infant up in a prone position while supporting his chest.The nurse looks for what normal response?

A 59-year-old patient a herniated intervertebral disk.Which of the following findings would the nurse expect to see on physical assessment of this individual?

A patient is not able to perform rapid alternating movements such as patting her knees rapidly.The nurse would document this as:

During the assessment of deep tendon reflexes,the nurse finds that a patient's responses are normal bilaterally.Indicate what number is used to indicate "normal" deep tendon reflexes when the documenting this finding.Fill in the blank. ____________ +

Which of the following statements is accurate concerning areas of the brain?

A 32-year-old woman tells the nurse that she has noticed "very sudden,jerky movements" mainly in her hands and arms."They seem to come and go,primarily when I am trying to do something.I haven't noticed them when I'm sleeping." This description suggests:

During the neurologic assessment of a "healthy" 35-year-old patient the nurse asks him to relax his muscles completely.The nurse then moves each extremity through full range of motion.Which of the following would the nurse expect to find?

The nurse places a key in the hand of a patient and he identifies it as a penny.What term would the nurse use to describe this finding?

During an assessment of a 22-year-old woman who has a head injury from a car accident 4 hours ago,the nurse notes the following change: pupils were equal,but now the right is fully dilated and nonreactive,left is 4 mm and reacts to light.What would finding this suggest?

When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed,he starts to sway and moves his feet further apart.The nurse would document this finding as a(n) :