43

Chapter 43: Assessment of the Nervous System
Test Bank
MULTIPLE CHOICE
1. The nurse assesses a client who has trauma to the cerebrum. Which clinical manifestation
does the nurse expect to observe?

Poor coordination
Memory loss
Hyperthermia
Slurred speech
a.
b.
c.
d.
ANS: B
The cerebrum is the largest part of the brain and controls intelligence, creativity, and memory.
Poor coordination, hyperthermia, and slurred speech are caused by other parts of the brain.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
2. The nurse is assessing a client with a frontal lobe brain injury. Which clinical manifestation
does the nurse expect to see?

Inability to interpret taste sensations
Inability to interpret sound
Impaired judgment
Impaired learning
a.
b.
c.
d.
ANS: C
The frontal lobe is responsible for many functions, including judgment, reasoning, voluntary
eye movement, and motor functions. The other clinical manifestations are not associated with
the frontal lobe.
DIF: Cognitive Level: Knowledge/Remembering
REF: Table 43-1, p. 907
3. The nurse is planning to provide discharge teaching related to cardiac medications to a client
who has experienced damage to the left temporal lobe of the brain. What does the nurse do to
assist the client to understand the content of the instruction?
a. Use a larger print size for written materials.
b. Ensure that the client is wearing glasses.
c. Point out the color of the medication.
d. Sit on the clients right side.
ANS: D
The temporal lobe contains the auditory center for sound interpretation. The clients hearing
will be impaired in the left ear. The nurse should sit on the clients right side and speak to the
right ear. The other interventions do not address the clients left temporal lobe damage.
REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Teaching/Learning

4. After performing a physical assessment on a 75-year-old client, the nurse notes that the client
has a hypoactive response to a test of deep tendon reflexes. Which intervention does the nurse
include in this clients plan of care?
a. Assist the client with ambulation.
b. Elevate the clients lower extremities.
c. Apply elastic support hose.
d. Massage the clients legs.
ANS: A
The older adult experiences certain neurologic changes associated with aging. Hypoactive
deep tendon reflexes and loss of vibration sense can impair balance and coordination,
predisposing the client to falls. The nurse or assistive personnel should assist this client with
ambulation to prevent injury. The other interventions do not address the clients problem.
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process)
MSC: Integrated Process: Nursing Process (Implementation)
5. The nurse is discharging an 80-year-old client with diminished touch sensation. Which
instruction does the nurse provide to promote client safety?

Walk barefoot only in your home.
Bathe in warm water to increase your circulation.
Look at the placement of your feet when walking.
Put throw rugs at the foot of your bed for cushioning.
a.
b.
c.
d.
ANS: C
Older clients with decreased sensation are at risk of injury from the inability to sense changes
in terrain when walking. To compensate for this loss, the client is instructed to look at the
placement of her or his feet when walking. The client also should wear sturdy shoes for
ambulation. Throw rugs can slip and increase fall risk. Bath water that is too warm places the
client at risk for thermal injury.
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
6. A client admitted the previous day for a suspected neurologic disorder becomes increasingly
lethargic. Which is the best nursing action?

Promote a quiet atmosphere for sleep and rest to treat the clients sleep deprivation.
Explain to the family that this is a normal age-related decline in mental processing.
Consult a psychiatrist to treat the clients hospital-acquired depression.
Complete a full neurologic assessment and notify the neurologist.
a.
b.
c.
d.
ANS: D
A change in the clients level of consciousness (LOC) is the first indication of a decline in
central neurologic functioning. The nurse should conduct a thorough assessment and then
should notify the neurologist (or other provider). The other interventions are inappropriate.
REF: N/A
MSC: Integrated Process: Nursing Process (Analysis)

7. The nurse is assessing a clients remote memory. Which statement by the client confirms that
remote memory is intact?

Mary had a little lamb whose fleece was white as snow.
I was born on April 3, 1967, in Johnstown Community Hospital.
Apple, chair, and pencil are the words you just stated.
My sister brought me to the clinic for this appointment.
a.
b.
c.
d.
ANS: B
Asking clients about certain facts from the past that can be verified assesses remote, or longterm, memory. The clients ability to make up a rhyme tests not memory, but rather a higher
level of cognition. The other statements indicate immediate and recent memory.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction in Risk PotentialSystem-Specific
Assessments)
8. During a neurologic examination, a client demonstrates a positive Rombergs sign with eyes
closed, but not with eyes open. Which condition does the nurse associate with this finding?
Difficulty with proprioception
Peripheral motor disorder
Impaired cerebellar function
Positive pronator drift
a.
b.
c.
d.
ANS: A
The client who sways with eyes closed (positive Rombergs sign) but not with eyes open most
likely has a disorder of proprioception and uses vision to compensate for it. The other options
do not explain a positive Rombergs sign.
REF: N/A
9. The nurse is assessing the deep tendon reflexes of a client with long-standing diabetes
mellitus. Which clinical manifestation does the nurse expect to see?

Bilateral hypoactive reflexes
Bilateral hyperactive reflexes
Asymmetric reflex response
Bilateral ankle clonus
a.
b.
c.
d.
ANS: A
Long-standing diabetes mellitus causes peripheral neuropathy. Hypoactive responses or no

response to stimulation of deep tendon reflexes is one manifestation of diabetes-induced
peripheral neuropathy. Other responses are not related to complications of diabetes mellitus.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
10. During a neurologic assessment of a client, the nurse notes that the clients arms, wrists, and
fingers have become flexed, and internal rotation and plantar flexion of the legs are evident.
How does the nurse document these findings?
a. Decorticate posturing
b. Decerebrate posturing
c. Atypical hyperreflexia
d. Spinal cord degeneration
ANS: A
The client is demonstrating decorticate posturing, which is seen with interruption in the
corticospinal pathway. This finding is abnormal and is a sign that the clients condition has
deteriorated. The physician, the charge nurse, and other health care team members should be
notified immediately of this change in status. Decerebrate posturing consists of external
rotation and extension of the extremities. The other two options are inaccurate.
REF: N/A
MSC: Integrated Process: Communication and Documentation
11. The nurse is evaluating a clients physical assessment with the medical history and treatment
plan. The nurse notes that the clients right pupil appears dilated, with a sluggish pupillary
response to light. Which disorder and related treatment does this physical finding correlate
with?
a. Coronary artery disease and beta blockers
b. Diabetes mellitus and oral glycemic reducing agents
c. Glaucoma and intraocular pressurereducing eyedrops
d. Myopia and corrective laser surgery
ANS: C
Clients with glaucoma who are being treated with eyedrops have unequal pupils, especially if
only one eye is being treated. The pupillary reaction to light is slowed by the use of eyedrops
for glaucoma. The other disorders and treatments do not correlate with the clinical assessment.
REF: N/A
12. Before electroencephalography, a client asks, Why will I be asked to take deep breaths
during the procedure? How does the nurse respond?

a. Hyperventilation causes cerebral vasodilatation and increases the likelihood of
seizure activity.
b. Hyperventilation causes cerebral vasoconstriction and increases the likelihood of
seizure activity.
c. Deep breathing will keep you relaxed and will lower the seizure threshold.
d. Deep breathing will make you hypoxemic, which lowers the seizure threshold.
ANS: B
Hyperventilation produces cerebral vasoconstriction and alkalosis, which increases the

likelihood of seizure activity. The client is asked to breathe deeply 20 to 30 times for 3
minutes. The other responses are not appropriate.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests)
MSC:
Integrated Process: Teaching/Learning
13. The nurse is caring for a client post-cerebral angiography via the clients right femoral artery.
Which intervention does the nurse implement?

Check the right lower extremity pulses.
Measure orthostatic blood pressure.
Perform a funduscopic examination.
Assess the clients gag reflex.
a.
b.
c.
d.
ANS: A
Cerebral angiography is performed by threading a catheter through the femoral or brachial

artery. The extremity is kept immobilized after the procedure. The nurse checks the extremity
for adequate circulation by noting skin color and temperature, presence and quality of pulses
distal to the injection site, and capillary refill. Clients usually are on bedrest; therefore
orthostatic blood pressure cannot be performed. The funduscopic examination would not be
affected by cerebral angiography. The client is given analgesics but not conscious sedation;
therefore the clients gag reflex would not be compromised.
REF: N/A
Complications from Diagnostic Tests/Treatments/Procedures)
14. The nurse is preparing a client for magnetic resonance angiography. Which question is a
priority at this time?

Have you had a recent blood transfusion?
Do you have allergies to iodine or shellfish?
Do you have a history of urinary tract infections?
Do you currently use oral contraceptives?
a.
b.
c.
d.
ANS: B
Allergies to iodine and/or shellfish need to be explored because the client may have a similar
reaction to the dye used in the procedure. In some cases, the client may need to be medicated
with antihistamines or steroids before the test is given. The other conditions would not affect
the angiography.
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control
Accident/Injury Prevention) MSC:
Integrated Process: Nursing Process (Assessment)
15. The nurse is caring for a client who had a computed tomography (CT) scan of the head with
contrast medium. Which priority intervention does the nurse implement?

Maintain bedrest with the head of the bed elevated less than 30 degrees.
Apply a pressure dressing to the site of injection.
Increase fluid intake after the procedure.
Maintain sedation for 8 hours postprocedure.
a.
b.
c.
d.
ANS: C
If a contrast medium is used, intravenous fluid may be given to promote excretion of the
contrast medium. Contrast medium also may act as a diuretic, resulting in the need for fluid
replacement. The client will not be sedated for the procedure and will not require bedrest.
Contrast is injected through a peripheral IV.
REF: N/A
16. The nurse is obtaining the health history of a client scheduled for magnetic resonance imaging
(MRI). Which condition requires the nurse to cancel the MRI?

Amputated leg
Internal insulin pump
Intrauterine device
Atrioventricular (AV) graft
a.
b.
c.
d.
ANS: B
Metal devices such as pacemakers and prostheses interfere with the accuracy of the image and
can become displaced by the magnetic force generated by an MRI procedure. An intrauterine
device and an AV graft do not contain any metal.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 921
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)
MSC: Integrated Process: Nursing Process (Planning)
17. Which priority instruction or precaution does the nurse teach a client who is scheduled for a
positron emission tomography scan of the brain?

Avoid caffeine-containing substances for 12 hours before the test.
Drink at least 3 liters of fluid during the 24 hours after the test.
Do not take your cardiac medication on the morning of the test.
Remove your dentures and any metal before the test begins.
a.
b.
c.
d.
ANS: A
Caffeine-containing liquids and foods are central nervous system stimulants and may alter the
test results. No contrast is used; therefore the client does not need to increase fluid intake. The
test does not require MRI, so metal does not have to be removed. The client should take
cardiac medications as prescribed.
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)
MSC: Integrated Process: Nursing Process (Planning)
18. A female client with deteriorating neurologic function states, I am worried I will not be able
to care for my young children. How does the nurse respond?

a. Caring for your children is a priority. You may not want to ask for help, but you
have to.
b. Our community has resources that may help you with some household tasks so
you have energy to care for your children.

c. You seem distressed. Would you like to talk to a psychologist about adjusting to
your changing status?
d. Give me more information about what worries you, so we can see if we can do
something to make adjustments.

ANS: D
Investigate specific concerns about situational or role changes before providing additional
information. The nurse should tell the client what is or is not a priority for her. Although
community resources may be available, they may not be appropriate for the client. Consulting
a psychologist would not be appropriate.
REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Communication and Documentation
19. The nurse is planning care for an 83-year-old client with age-related changes to his sensory
perception. Which nursing action does the nurse implement to ensure the clients safety?
a. Provide a call button that requires only minimal pressure to activate.
b. Use a clock and a calendar to orient and minimize onset of dementia.
c. Ensure that the path to the bathroom is free from equipment.
d. Admit the client to the room closest to the nursing station.
ANS: C
Dementia and confusion are not common phenomena in older adults. However, physical
impairment related to illness can be expected. Providing opportunities for hazard-free
ambulation will maintain strength and mobility (and ensure safety). The other actions are not a
priority.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort
Mobility/Immobility)
20. A client is scheduled for a single-photon emission computed tomography test. Which
condition in the clients history causes the nurse to contact the provider before the test takes
place?
a. Peptic ulcers
b. Smoking history
c. Liver failure
d. Currently breast feeding
ANS: D
A SPECT test uses radiopharmaceutical agents that enable radioisotopes to cross the bloodbrain barrier. This test is contraindicated in women who are breast-feeding. Having a history
of smoking, peptic ulcers, or liver failure should not interfere with the client having this test.
REF: N/A
21. The nurse is teaching a client before magnetic resonance imaging (MRI). Which statement
indicates that the client understands the content of the education?

a. I need to stay away from heavy metals for the next 48 hours.
b. My urine will be radioactive for the next 48 hours.
c. I must increase my fluids because of the dye used for the MRI.
d. I can return to my usual activities immediately after the MRI.
ANS: D
No postprocedure restrictions are imposed after MRI. The client can return to normal
activities after the test is complete.
REF: N/A
22. While assessing pain discrimination, a client correctly identifies, with eyes closed, a sharp
sensation on the right hand when touched with a pin. How does the nurse then proceed with
the examination?
a. Touch the pin on the same area of the left hand.
b. Touch the pin on the right forearm.
c. Touch the pin on the right upper arm.
d. Touch the right hand with a drop of cold water.
ANS: A
If testing is begun on the hand and the client correctly identifies the pain stimulus, testing
more proximal parts of that extremity is not necessary because, if the distal tract is intact, so
are the proximal areas. Temperature discrimination is not necessary because the same tract
transmits both pain and temperature sensation.
REF: p. 915
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-Specific
Assessments)
23. The nurse is assessing a client scheduled for a lumbar puncture. Which clinical manifestation
assessed by the nurse complicates the lumbar puncture procedure?

Normal intracranial pressures
Allergy to iodine or shellfish
Restlessness and agitation
Eating lunch less than 2 hours ago
a.
b.
c.
d.
ANS: C
Clients must be able to hold still during the procedure. If a client is restless or agitated,
assistance may be needed to ensure that the procedure is completed safely. Lumbar puncture is
not performed on clients with severely high intracranial pressure. Allergies to iodine and
shellfish or eating lunch 2 hours before the procedure have no effect on the procedure.
REF: p. 925
24. On assessment of the left plantar reflexes of an adult client, the nurse notes the response
shown in the photograph below. What action does the nurse take after assessing this new
finding?
a.
b.
c.
d.
Relay this abnormal finding to other members of the health care team.
Anticipate the need for cerebral angiography to determine the cause.
Examine the family history for a potential genetic disorder.
Document the finding and continue the assessment.
ANS: A
This finding is a positive Babinski reflex. In clients older than 2 years of age, a positive
Babinski reflex is considered abnormal and indicates central nervous system disease. The
nurse should notify the health care provider and other members of the health care team
because further investigation is warranted.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Pathophysiology)
MULTIPLE RESPONSE
1. In a client with an injury to the medulla, the nurse monitors for which clinical manifestations
secondary to damage of cranial nerves that emerge from the medulla? (Select all that apply.)
Loss of smell
Impaired swallowing
Blink reflex
Visual changes
Inability to shrug shoulders
Loss of gag reflex
a.
b.
c.
d.
e.
f.
ANS: B, E, F
Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal)

emerge from the medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic).
Damage to these nerves causes impaired swallowing, inability to shrug shoulders, and loss of
the gag reflex. The other manifestations are not associated with damage to the medulla.
REF: Table 43-2, p. 908

2. The nurse is assessing a client with a temporal lobe injury. Which clinical manifestations
correlate with this injury? (Select all that apply.)

Memory loss
Personality changes
Loss of temperature regulation
Difficulty with sound interpretation
Speech difficulties
Impaired taste
a.
b.
c.
d.
e.
f.
ANS: A, D, E
Wernickes area (language area) is located in the temporal lobe and enables processing of
words into coherent thought and understanding of written or spoken words. The temporal lobe
also is responsible for the auditory centers interpretation of sound and complicated memory
patterns. Personality changes are related to damage to frontal lobe injury. Loss of temperature
regulation is seen with damage to the hypothalamus, and impaired taste is associated with
injury to the parietal lobe.
REF: Table 43-1, p. 907
3. The nurse is administering a medication to a client that stimulates the sympathetic division of
the autonomic nervous system. Which clinical manifestations does the nurse monitor for?
(Select all that apply.)
a. Decreased heart rate
b. Increased heart rate
c. Decreased force of contraction
d. Increased force of contraction
e. Decreased respirations
ANS: B, D
Stimulation of the sympathetic nervous system initiates the fight-or-flight response, increasing
both the heart rate and the force of contraction. The other three options do not occur with
sympathetic nervous system stimulation.
REF: N/A
COMPLETION
1. Immediately after a lumbar puncture, the client begins to vomit and an IV is started with
normal saline (0.9% NS). The provider orders a 200-mL bolus over 15 minutes. Using an
infusion pump that delivers mL/hr, the rate at which the nurse sets the pump is _____ mL.
ANS:
800
200 mL/15 min = x mL/60 min
200 mL/15 min = 800 mL/60 min

15x = 12,000
x = 800 mL
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Dosage Calculation)

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Chapter 43: Assessment of the Nervous System

does the nurse expect to observe?

does the nurse expect to see?

MSC: Integrated Process: Teaching/Learning

instruction does the nurse provide to promote client safety?

lethargic. Which is the best nursing action?

MSC: Integrated Process: Nursing Process (Analysis)

remote memory is intact?

mellitus. Which clinical manifestation does the nurse expect to see?

Long-standing diabetes mellitus causes peripheral neuropathy. Hypoactive responses or no

during the procedure? How does the nurse respond?

Hyperventilation produces cerebral vasoconstriction and alkalosis, which increases the

Which intervention does the nurse implement?

Cerebral angiography is performed by threading a catheter through the femoral or brachial

priority at this time?

contrast medium. Which priority intervention does the nurse implement?

(MRI). Which condition requires the nurse to cancel the MRI?

positron emission tomography scan of the brain?

to care for my young children. How does the nurse respond?

you have energy to care for your children.

your changing status?

something to make adjustments.

indicates that the client understands the content of the education?

assessed by the nurse complicates the lumbar puncture procedure?

Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal)

REF: Table 43-2, p. 908

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

correlate with this injury? (Select all that apply.)

200 mL/15 min = 800 mL/60 min

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