Chapter 60- Assessment of Neurologic Function
Chapter 60: Assessment of Neurologic Function
Multiple Choice
1. The nurse assessing a patient with a
... [Show More] head injury due to a motor vehicle accident who is
experiencing temporary blindness in the left eye would be correct in documenting this abnormal
finding as corresponding to which of the following cerebral lobes?
A) Temporal
B) Occipital
C) Parietal
D) Frontal
Ans: B
Chapter: 60
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 1
Patient Needs: A-1
Feedback: The posterior (occipital) lobe of the cerebral hemisphere is responsible for visual
interpretation. The temporal lobe contains the auditory receptive areas. The parietal lobe contains
the primary sensory cortex and is essential to an individual's awareness of the body in space, as
well as orientation in space and spatial relations. The frontal lobe functions in concentration,
abstract thought, information storage or memory, and motor function.
2. A nurse completing a neurological exam on a patient with Ménière's disease is assessing
cranial nerve VIII. The nurse would be correct in identifying the function of this nerve as which
of the following?
A) Movement of the tongue
B) Visual acuity
C) Sense of smell
D) Hearing and equilibrium
Ans: D
Chapter: 60
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 1
Patient Needs: A-1
Feedback: Cranial nerve VIII (acoustic) is responsible for hearing and equilibrium. Cranial
nerve XII (hypoglossal) is responsible for movement of the tongue. Cranial nerve II (optic) is
responsible for visual acuity and visual fields. Cranial nerve I (olfactory) functions in sense of
smell. Refer to Table 60-02.
3. The nurse assessing a patient who exhibits an uncoordinated gait knows that which of the
following brain structures affects balance and coordination?
A) Cerebellum
B) Pons
C) Medulla
D) Midbrain
Ans: A
Chapter: 60
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 1
Patient Needs: A-1
Feedback: The cerebellum controls fine movement, balance, position sense, and integration of
sensory input. Portions of the pons control the heart, respiration, and blood pressure. Cranial
nerves IX through XII connect to the brain in the medulla. Cranial nerves III and IV originate in
the midbrain.
4. A patient is scheduled for an electroencephalography (EEG) to aid in the diagnosis of a
seizure disorder. Appropriate patient teaching for this diagnostic test would include which of the
following?
A) Sedation will be given prior to the test.
B) The patient will be NPO prior to the test.
C) The patient may be sleep deprived prior to the test.
D) Coffee can be consumed in the meal prior to the test.
Ans: C
Chapter: 60
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 6
Patient Needs: A-1
Feedback: To increase the chances of recording seizure activity, it is sometimes recommended
that the patient be deprived of sleep on the night before the EEG. Sedation is not advisable as it
may lower the seizure threshold in patients with seizure disorder and alter brain activity in all
patients. The meal is not omitted prior to the test because an altered blood glucose level can
cause changes in the brain-wave patterns. Coffee, tea, chocolate, and cola drinks are prohibited
in the meal before the test because of their stimulating effect.
5. To assess function of cranial nerve VIII, the nurse would be correct in completing which of
the following assessment techniques?
A) Have the patient identify familiar odors with his eyes closed
B) Assess papillary reflex
C) Utilize the Snellen chart
D) Test for air and bone conduction (Rinne's test)
Ans: D
Chapter: 60
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 2
Patient Needs: A-1
Feedback: Cranial nerve VIII is the acoustic nerve. It functions in hearing and equilibrium.
When assessing this nerve, the nurse would test for air and bone conduction (Rinne's test) with a
tuning fork. Assessment of papillary reflex would be completed for cranial nerves III
(oculomotor), IV (trochlear), and VI (abducens). Utilization of the Snellen chart would be used
to assess cranial nerve II (optic). Refer to Chart 60-01.
6. The patient is receiving a cholinergic medication. With knowledge of the parasympathetic
nervous system (PNS), the nurse would expect to find which of the following clinical
manifestations?
A) Diaphoresis
B) Decreased bowel sounds
C) Hypotension
D) Pupil dilation
Ans: C
Chapter: 60
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 1
Patient Needs: D-2
Feedback: Cholinergic medications decrease blood pressure. Adrenergic medications cause
increased secretion of sweat, decreased peristaltic movements of the digestive tube, and dilation
of the pupil. Refer to Table 60-03.
7. A patient has an upper motor neuron lesion. The nurse would be correct in assessing for which
of the following during assessment of the patient's lower extremities?
A) Muscle spasticity
B) Hyporeflexia
C) Decreased muscle tone
D) Muscle atrophy
Ans: A
Chapter: 60
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 2
Patient Needs: A-1
Feedback: Upper motor neuron lesions cause muscle spasticity, increased muscle tone, and loss
of voluntary control. Lower motor neuron lesions cause decreased muscle tone, hyporeflexia,
and muscle atrophy. Refer to Table 60-04.
8. The nurse preparing a patient for magnetic resonance imaging (MRI) would include which of
the following?
A) Withhold stimulants 24 to 48 hours prior to exam
B) Remove all metal-containing objects
C) Instruct the patient to void prior to exam
D) Initiate an intravenous line for administration of contrast
Ans: B
Chapter: 60
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 6
Patient Needs: A-1
Feedback: Patient preparation for an MRI consists of removing all metal-containing objects
prior to the exam. Withholding stimulants would not affect an MRI; this relates to an
electroencephalography (EEG). Instructing the patient to void is patient preparation for a lumbar
puncture. Initiating an intravenous line for administration of contrast would be done if the patient
were having a CT scan with contrast.
9. The nurse is assisting with a lumbar puncture in a patient with an intracranial mass. The
cerebrospinal fluid (CSF) is sent to the lab for analysis. The nurse knows that a normal CSF test
is positive for which of the following?
A) Glucose
B) Potassium
C) Creatinine
D) Blood
Ans: A
Chapter: 60
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 6
Patient Needs: A-1
Feedback: Normal CSF tests positive for glucose. CSF does not contain potassium or creatinine.
Blood-tinged, pink, or grossly bloody CSF may indicate a cerebral contusion, laceration, or
subarachnoid hemorrhage. Refer to Appendix B, Table B-5.
10. The nurse caring for an 83-year-old patient with Alzheimer's disease knows that which of the
following is a normal neurological change in the aging process?
A) Hyperactive deep tendon reflexes
B) Reduction in cerebral blood flow (CBF)
C) Increased cerebral metabolism
D) Hypersensitivity to painful stimuli
Ans: B
Chapter: 60
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 5
Patient Needs: B
Feedback: Reduction in cerebral blood flow (CBF) is a change that occurs in the normal aging
process. Deep tendon reflexes can be decreased or in some cases absent. Cerebral metabolism
decreases as the patient advances in age. Reaction to painful stimuli may be decreased with age.
Because pain is an important warning signal, caution must be used when hot or cold packs are
used. [Show Less]