MSII Prep U Ch.
65 Assessment of Neurologic Function
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1. After a plane crash, a client is brought to the emergency
department with severe burns and respiratory difficulty. The
nurse helps to secure a patent airway and attends to the
client's immediate needs, then prepares to perform an initial
neurologic assessment. The nurse should perform an::
evaluation of the corneal reflex response.
During an acute crisis, the nurse should check the corneal
reflex response to rapidly assess brain stem function. Other
components of the brief initial neurologic assessment usually
include level of consciousness, pupillary response, and motor
response in the arms and legs. If appropriate and if time
permits, the nurse also may assess sensory responses of the
arms and legs. Emergency assessment doesn't include fundus
examination unless the client has sustained direct eye trauma.
The client shouldn't be moved unnecessarily until the extent of
injuries is known, making gait evaluation impossible. Bowel and
bladder functions aren't vital, so the nurse should delay their
assessment.
2. A client has sustained a head injury to the occipital area. He
cannot identify a familiar object by looking at it. The nurse
knows that this deficit is which of the following?: Visual
agnosia
Visual agnosia is the loss of ability to recognize objects when
seeing them. The Romberg test has to do with balance. Ataxia
is defined as incoordination of voluntary muscle action.
Astereognosis is the inability to identify an object by touch.
3. A client is diagnosed with a brain tumor. The nurse's
assessment reveals that the client has difficulty interpreting
visual stimuli. Based on these findings, the nurse suspects
injury to which lobe of the brain?: Occipital
The occipital lobe is responsible for interpreting visual stimuli.
The frontal lobe influences personality, judgment, abstract
reasoning, social behavior, language expression, and
movement. The temporal lobe controls hearing, language
comprehension, and storage and memory recall (although
memory recall is also stored throughout the brain). The
parietal lobe interprets and integrates sensations, including
pain, temperature, and touch; it also interprets size, shape,
distance, and texture.
4. A client is waiting in a triage area to learn the medical status
of family members following a motor vehicle accident. The
client is pacing, taking deep breaths, and handwringing.
Considering the effects in the body systems, the nurse
anticipates that the liver will: convert glycogen to glucose for
immediate use.
When the body is under stress, the sympathetic nervous
system is activated readying the body for action. The effect of
the body is to mobilize stored glycogen to glucose to provide
additional energy for body action.
5. A client preparing to undergo a lumbar puncture states he
doesn't think he will be able to get comfortable with his
knees drawn up to his abdomen and his chin touching his
chest. He asks if he can lie on his left side. Which statement
is the best response by the nurse?: "Although the required
position may not be comfortable, it will make the procedure
safer and easier to perform."
The nurse should explain that the knee-chest position is
necessary to make the procedure safer and easier to perform.
Lying on his left side won't make the procedure easy or safe to
perform. The nurse shouldn't simply tell the client there is no
other option because the client is entitled to understand the
rationale for the required position. Reporting the client's
concerns to the physician won't meet the client's needs in this
situation.
6. A client who has sustained a head injury to the parietal lobe
cannot identify a familiar object by touch. The nurse knows
that this deficit is which of the following?: Tactile agnosia
Tactile agnosia is the inability to identify a familiar object by
touch. Visual agnosia is the loss of ability to recognize objects
through sight. The Romberg test has to do with balance. Ataxia
is defined as incoordination of voluntary muscle action.
7. A client with a suspected brain tumor is scheduled for a
computed tomography (CT) scan. What should the nurse do
when preparing the client for this test?: Determine whether
the client is allergic to iodine, contrast dyes, or shellfish.
Because CT commonly involves use of a contrast agent, the
nurse should determine whether the client is allergic to iodine,
contrast dyes, or shellfish. Neck immobilization is necessary
only if the client has a suspected spinal cord injury. Placing a
cap over the client's head may lead to misinterpretation of test
results; instead, the hair should be combed smoothly. The
physician orders a sedative only if the client can't be expected
to remain still during the CT scan.
8. During a routine physical examination to assess a client's
deep tendon reflexes, a nurse should make sure to:: support
the joint where the tendon is being tested
The nurse should support the joint where the tendon is being
tested to prevent the attached muscle from contracting. The
nurse should use the flat, not pointed, end of the reflex
hammer when striking the Achilles tendon. (The pointed end is
used to strike over small areas, such as the thumb placed over
the biceps tendon.) Tapping the tendon slowly and softly
wouldn't provoke a deep tendon reflex response. The nurse
should hold the reflex hammer loosely, not tightly, between
the thumb and fingers so it can swing in an arc.
9. A female patient has undergone a lumbar puncture for a
neurological assessment. The patient is put under the
postprocedure care of a nurse. Which of the following
important postprocedure nursing interventions should be
performed to ensure maximum comfort to the patient?:
Encourage a liberal fluid intake for the patient
The nurse should encourage the patient to take liberal fluids
and inspect the injection site for swelling or hematoma. These
measures help restore the volume of CSF extracted. The
patient is administered antihistamines before a test only if he
or she is allergic to contrast dye and contrast dye will be used.
The room of the patient who has undergone a lumbar
puncture should be kept dark and quiet. The patient should be
encouraged to rest, because sensory stimulation tends to
magnify discomfort.
10. Lesions in the temporal lobe may result in which of the
following types of agnosia?: Auditory
Lesions in the temporal lobe (lateral and superior portions)
may result in auditory agnosia. Lesions in the occipital lobe
may result in visual agnosia. Lesions in the parietal lobe may
result in tactile agnosia. Lesions in the parietal lobe
(posteroinferior regions) may result in relationship and body
part agnosia.
11. Lower motor neuron lesions cause: flaccid muscle paralysis.
Lower motor neuron lesions cause flaccid muscle paralysis,
muscle atrophy, decreased muscle tone, and loss of voluntary
control. Upper motor neuron lesions cause increased muscle
tone. Upper motor neuron lesions cause no muscle atrophy.
Upper motor neuron lesions cause hyperactive and abnormal
reflexes
12. Low levels of the neurotransmitter serotonin lead to which of
the following disease processes?: Depression
A decrease of serotonin leads to depression. A decrease in
the amount of acetylcholine causes myasthenia gravis.
Parkinson's disease is caused by a depletion of dopamine.
Decreased levels of GABA may cause seizures.
13. A male client is scheduled for an electroencephalogram
(EEG). When the nurse caring for the client is preparing him
for the test, the client states that during childhood he was
mildly electrocuted but miraculously lived. Therefore, he is
quite afraid of going through an EEG. In what ways can the
nurse help dispel the client's fear regarding the test?: Inform
the client that he will not experience any electrical shock.
An EEG records the electrical impulses generated by the brain.
To prepare the client for the test, the nurse informs the client
that he or she will not experience any electrical shock. The
source of electrical energy is the client's neural activity within
the brain and not any external electrical energy. Ensuring
adequate water intake or distracting the attention of the client
will not comfort the client about the technical nature of the
test.
14. A male patient is scheduled for an EEG. The patient inquires
about any diet-related prerequisites that he must take. Which
of the following diet-related advice should the nurse provide
to the patient?: Avoid taking sedative drugs or drinks that
contain caffeine for at least 8 hours prior to the test
The patient is advised to refrain from taking sedative drugs or
drinks that contain caffeine for at least 8 hours prior to the test
because these may interfere with the EEG test result. The
patient is not advised to increase or decrease the intake of
minerals in the diet.
15. A nurse and nursing student are caring for a client recovering
from a lumbar puncture yesterday. The client reports a
headache despite being on bedrest overnight. The physician
plans an epidural blood patch this morning. The student asks
how this will help the headache. The correct reply from the
nurse is which of the following?: "The blood will seal the hole
in the dura and prevent further loss of cerebral spinal fluid."
Loss of CSF causes the headache. Occasionally, if the
headache persists, the epidural blood patch technique may be
used. Blood is withdrawn from the antecubital vein and
injected into the site of the previous puncture. The rationale is
that the blood will act as a plug to seal the hole in the dura
and preven further loss of CSF. The blood is not put into the
subarachnoid space. The needle is inserted below the level of
the spinal cord, which prevents damage to the cord. It is not a
lack of moisture that prevents healing; it is more related to the
size of the needle used for the puncture.
16. The nurse is assessing the client's pupils following a sports
injury. Which of the following assessment findings indicates a
neurologic concern? Select all that apply: Unequal pupils
Pinpoint pupils
Absence of pupillary response
Normal assessment findings includes that the pupils are equal
and reactive to light. Pupils that are unequal, pinpoint in nature,
or fail to respond indicate a neurologic impairment.
17. The nurse is assessing the mental status of a patient. Which of
the following questions will the nurse include in the
assessment?: "Who is the president of the United States?"
Assessing orientation to time, place, and person assists in
evaluating mental status. Does the patient know what day it is,
what year it is, and the name of the president of the United
States? Is the patient aware of where he or she is? Is the
patient aware of who the examiner is and of his or her purpose
for being in the room? "Can you write your name on this piece
of paper?" will assess language ability. "Can you count
backward from 100?" assesses the patient's intellectual
function. "Are you having hallucinations?" assesses the patient's
thought content.
18. A nurse is assisting during a lumbar puncture. How should the
nurse position the client for this procedure?: Lateral
recumbent, with chin resting on flexed knees
To maximize the space between the vertebrae, the client is
placed in a lateral recumbent position with knees flexed
toward the chin. The needle is inserted between L4 and L5. The
other positions wouldn't allow as much space between L4 and
L5.
19. A nurse is caring for a client with deteriorating neurologic
status. The nurse is performing an assessment at the
beginning of the shift that reveals a falling blood pressure
and heart rate, and the client makes no motor response to
stimuli. Which documentation of neuromuscular status is
most appropriate?: Flaccidity
The nurse would document flaccidity when the client makes no
motor response to stimuli. Abnormal posturing and weak
motor tone would be documented specifically as the nurse
would assess. Decorticate posturing is when a client is stiff
with bent arms and clenched fists with legs straight out.
20. A nurse is completing a neurological assessment and
determines that the client has significant visual deficits. A
brain tumor is considered. Considering the functions of the
lobes of the brain, which area will most likely contain the
neurologic deficit?: Occipital
The vision center is located in the occipital lobe. There is little
other functioning that may interfere with the visual process in
the other lobes of the brain.
21. A nurse is completing a neurological assessment and
determines that the client has significant visual deficits.
Considering the functions of the lobes of the brain, which
area will most likely contain the neurologic deficit?: occipital
The vision center is located in the occipital lobe. There is little
that may interfere with the visual process in the other lobes of
the brain.
22. The nurse is completing a neurologic assessment and uses
the whisper test to assess which of the following cranial
nerves?: Acoustic
Clinical examination of the acoustic nerve can be done by the
whisper test. Having the patient say "ah" tests the vagus nerve.
Observing for symmetry when the patient performs facial
movements tests the facial nerve. The olfactory nerve is tested
by having the patient identify specific odors.
23. The nurse is instructing a community class when a student
asks, "How does someone get super strength in an
emergency?" The nurse should respond by describing the
action of the:: sympathetic nervous system.
The division of the autonomic nervous system called the
sympathetic nervous system regulates the expenditure of
energy. The neurotransmitters of the sympathetic nervous
system are called catecholamines. During an emergency
situation or an intensely stressful event, the body adjusts to
deliver blood flow and oxygen to the brain, muscles, and
lungs that need to react in the situation. The musculoskeletal
system benefits from the sympathetic nervous system as the
fight-or-flight effects pump blood to the muscles. The
parasympathetic nervous system works to conserve body
energy not expend it during an emergency. The endocrine
system regulates metabolic processes.
24. The nurse is performing a neurological assessment of a
client who has sustained damage to the frontal cortex. Which
of the following deficits will the nurse look for during
assessment?: The inability to tell how a mouse and a cat are
alike
The client with damage to the fronal cortex will display a
deficit in intellectual functioning. Questions designed to assess
this capacity might include the ability to recognize similarities:
for example, how are a mouse and dog or pen and pencil
alike? The Romberg test assesses balance, which has to do
with the cerebellar and basal ganglia influence on the motor
system. Absence of movement below the waist suggests a
deficit with the spinal cord. Intentional tremors have to do with
deficits of the motor system
25. A nurse is preparing a client for a lumbar puncture. The
client has heard about post-lumbar puncture headaches and
asks what causes them. The nurse tells the client that these
headches are caused by which of the following?: Cerebral
spinal fluid leakage at the puncture site
The headache is caused by cerebral spinal fluid (CSF) leakage
at the puncture site. The supply of CSF in the cranium is
depleted so that there is not enough to cushion and stabilize
the brain. When the client assumes an upright position, tension
and stretching of the venous sinuses and pain-sensitive
structures occur.
26. The nurse is preparing a client for a neurological examination
by the physician and explains tests the physician will be
doing, including the Romberg test. The client asks the
purpose of this particular test. The correct reply by the
nurse is which of the following?: "It is a test for balance."
The Romberg test screens for balance. The client stands with
feet together and arms at the side, first with eyes open and
then with both eyes closed for 20 to 30 seconds. Slight
swaying is normal, but a loss of balance is abnormal and is
considered a positive Romberg test.
27. A nurse is working in a neurologist's office. The physician
orders a Romberg test. The nurse should have the client::
close his or her eyes and stand erect.
In the Romberg test, the client stands erect with the feet close
together and eyes closed. If the client sways as if to fall, it is
considered a positive Romberg test. All of the other options
include components of neurologic tests, indicating neurologic
deficits and balance.
28. The nurse who is employed in a neurologist's office is
performing a history and assessment on a client
experiencing hearing difficulty. The nurse is most correct to
gather equipment to assess the function of cranial nerve::
VIII
There are 12 pairs of cranial nerves. Cranial nerve VIII is the
vestibulocochlear or auditory nerve responsible for hearing
and balance. Cranial nerve II is the optic nerve. Cranial nerve
VI is the abducens nerve responsible for eye movement.
Cranial nerve XI is the accessory nerve and is involved with
head and shoulder movement.
29. A patient has been diagnosed with damage to Broca's area of
the left frontal lobe. To document the extent of damage, the
nurse would assess the patient's:: Speech.
The motor strip, which lies in the frontal lobe, anterior to the
central sulcus, is responsible for muscle movement. It also
contains Broca's area (left frontal lobe region in most people),
critical for motor control of speech.
30. A patient is actively hallucinating during an assessment. The
nurse would be correct in documenting the hallucination as a
disturbance in which of the following?: Thought content
Hallucinations are a disturbance of thought content. They are
not disturbances in motor ability, intellectual function, or
emotional status.
31. A patient is being tested for a gag reflex. When the nurse
places the tongue blade to the back of the throat, there is no
response elicited. What dysfunction does the nurse
determine the patient has?: Dysfunction of the vagus nerve
The vagus nerve (cranial nerve X) controls the gag reflex and
is tested by depressing the posterior tongue with a tongue
blade. An absent gag reflex is a significant finding, indicating
dysfunction of this nerve.
32. A patient is having a lumbar puncture and the physician has
removed 20 mL of cerebrospinal fluid. What nursing
intervention is a priority after the procedure?: Have the
patient lie flat for 6 hours.
Post-lumbar puncture headache may be avoided if a small-
gauge needle is used and if the patient remains prone after the
procedure. When more than 20 mL of CSF is removed, the
patient is positioned supine for 6 hours (Bader & Littlejohns,
2010).
33. A patient is scheduled for standard EEG testing to evaluate a
possible seizure disorder. Nursing interventions prior to the
procedure include which of the following?: Withholding
antiseizure medications for 24 to 48 hours prior to the exam
Antiseizure agents, tranquilizers, stimulants, and depressants
should be withheld 24 to 48 hours before an EEG because
these medications can alter EEG wave patterns or mask the
abnormal wave patterns of seizure disorders. 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. Coffee, tea, chocolate, and cola drinks
are omitted in the meal before the test because of their
stimulating effect. However, the meal is not omitted, because
an altered blood glucose level can cause changes in brain
wave patterns. The patient is informed that the standard EEG
takes 45 to 60 minutes; a sleep EEG requires 12 hours.
34. A patient recently noted difficulty maintaining his balance
and controlling fine movements. The nurse explains that the
provider will order diagnostic studies for the part of his brain
known as the:: Cerebellum.
The cerebellum is largely responsible for coordination of all
movement. It also controls fine movement, balance, position
(postural) sense or proprioception (awareness of where each
part of the body is), and integration of sensory input.
35. The physician's office nurse is caring for a client who has a
history of a cerebral aneurysm. Which diagnostic test does
the nurse anticipate to monitor the status of the aneurysm?:
Cerebral angiography
The nurse would anticipate a cerebral angiography, which
detects distortion of the cerebral arteries and veins . A
myelogram detects abnormalities of the spinal canal. An
electroencephalogram records electrical impulses of the brain.
An echoencephalography is an ultrasound of the structures of
the brain.
36. To evaluate a client's cerebellar function, a nurse should ask::
"Do you have any problems with balance?"
To evaluate cerebellar function, the nurse should ask the client
about problems with balance and coordination. The nurse asks
about difficulty speaking or swallowing to assess the functions
of cranial nerves IX, X, and XII. Questions about muscle
strength help her evaluate the client's motor system.
37. Which cranial nerve is tested by listening to a ticking watch?:
Acoustic
The acoustic nerve (VIII) assesses hearing by rubbing the
fingers, placing a ticking watch, or whispering near each ear.
The facial nerve (VII) is assessed for symmetry of facial
movement. The trigeminal nerve (V) is assessed for facial
sensation, corneal reflex, and chewing or mastication. The
vagus nerve (X) is assessed by swallowing and gag reflex.
38. Which diagnostic procedure would the nurse anticipate first if
the goal was to obtain a thin slice of a muscular body area?:
computed tomography (CT)
A computer tomography scan uses x-rays and computer
analysis to produce three-dimensional views of the slices of
the body. This is a good first test to obtain information. An MRI
uses radiofrequency waves to produce images of tissue. PET
scans use radioactive substances to examine metabolic activity
and organ involvement. SPECT is an imaging tool that
examines cerebral blood flow.
39. Which lobe of the brain is responsible for concentration and
abstract thought?: Frontal
The major functions of the frontal lobe are concentration,
abstract thought, information storage or memory, and motor
function. The parietal lobe analyzes sensory information such
as pressure, vibration, pain, and temperature. The occipital
lobe is the primary visual cortex. The temporal lobe contains
the auditory receptive areas located around the temples.
40. Which neurons transmit impulses from the CNS?: Motor
Neurons are either sensory or motor. Sensory neurons transmit
impulses to the CNS; motor neurons transmit impulses from
the CNS. A membranous sheath called the neurilemma covers
the myelin of axons in peripheral nerves. Dendrites are
threadlike projections or fibers.
41. Which neurotransmitter demonstrates inhibitory action, helps
control mood and sleep, and inhibits pain pathways?:
Serotonin
The sources of serotonin are the brain stem, hypothalamus,
and dorsal horn of the spinal cord. Enkephalin is excitatory
and associated with pleasurable sensations. Norepinephrine is
usually excitatory and affects mood and overall activity.
Acetylcholine is usually excitatory, but the parasympathetic
effects are sometimes inhibitory.
42. Which of the following are sympathetic effects of the
nervous system?: Dilated pupils
Dilated pupils are a sympathetic effect of the nervous system.
Constricted pupils are a parasympathetic effect. Decreased
blood pressure is a parasympathetic effect. Increased blood
pressure is a sympathetic effect. Increased peristalsis is a
parasympathetic effect. Decreased peristalsis is a sympathetic
effect. Decreased respiratory rate is a parasympathetic effect.
Increased respiratory rate is a sympathetic effect.
43. Which of the following cerebral lobes contains the auditory
receptive areas?: Temporal
The temporal lobe plays the most dominant role of any area of
the cortex in cerebration. The frontal lobe, the largest lobe,
controls concentration, abstract thought, information storage
or memory, and motor function. The parietal lobe contains the
primary sensory cortex, which analyzes sensory information
and relays interpretation to the thalamus and other cortical
areas. The occipital lobe is responsible for visual
interpretation.
44. Which of the following cerebral lobes is the largest and
controls abstract thought?: Frontal
The frontal lobe also controls information storage or memory
and motor function. The temporal lobe contains the auditory
receptive area. The parietal lobe contains the primary sensory
cortex, which analyzes sensory information and relays
interpretation to the thalamus and other cortical areas. The
occipital lobe is responsible for visual interpretation.
45. Which of the following cranial nerves is responsible for
muscles that move the eye and lid?: Oculomotor
The oculomotor (III) cranial nerve is also responsible for
pupillary constriction and lens accommodation. The trigeminal
(V) cranial nerve is responsible for facial sensation, corneal
reflex, and mastication. The vestibulocochlear (VII) cranial
nerve is responsible for hearing and equilibrium. The facial
(VII) nerve is responsible for salivation, tearing, taste, and
sensation in the ear.
46. Which of the following safety actions will the nurse implement for a patient receiving oxygen therapy who is undergoing magnetic
resonance imaging (MRI)?: Ensure that no patient care equipment containing metal enters the room where the MRI table is located.

For patient safety, the nurse must make sure that no patient care equipment (eg, portable oxygen tanks) that contains metal or metal
parts enters the room where the MRI is located. The patient must be assessed for the presence of medication patches with foil backing
(e.g., nicotine) that may cause a burn. The magnetic field generated by the unit is so strong that any metal-containing items will be
strongly attracted and can literally be pulled away with such great force that they can fly like projectiles toward the magnet.
47. Which of the following terms is used to describe the fibrous connective tissue that covers the brain and spinal cord?: Meninges

The meninges have three layers, the dura mater, arachnoid mater, and pia mater. The dura mater is the outmost layer of the protective
covering of the brain and spinal cord. The arachnoid is the middle membrane of the protective covering of the brain and spinal cord.
The pia mater is the innermost membrane of the protective covering of the brain and spinal cord.
48. Which of the following terms refers to the inability to coordinate muscle movements, resulting difficulty walking?: Ataxia

Ataxia is the inability to coordinate muscle movements, resulting in difficulty walking. Agnosia is the loss of ability to recognize objects
through a particular sensory system.Spasticity is the sustained increase in tension of a muscle when it is passively lengthened or
stretched.
49. Which of the following terms refers to the inability to coordinate muscle movements, resulting in difficulty walking?: Ataxia

Ataxia is the inability to coordinate muscle movements, resulting in difficulty walking. Agnosia is the loss of ability to recognize objects
through a particular sensory system. Spasticity is the sustained increase in tension of a muscle when it is passively lengthened or
stretched.
50. Which of the following terms refer to a method of recording, in graphic form, the electrical activity of the muscle?: Electromyogram

Electromyogram is a method of recording, in graphic form, the electrical activity of the muscle. Electroencephalogram is a method of
recording, in graphic form, the electrical activity of the brain. Electrocardiography is performed to assess the electrical activity of the
heart. Electrogastrography is an electrophysiologic study performed to assess gastric motility disturbances.