Neurologic System

1. A nurse assesses a patient with a head injury who has slowing intellectual functioning, personality changes, and emotional lability. The nurse correlates these findings with which area of the brain?
a. Frontal lobe
b. Parietal lobe
c. Thalamus
d. Temporal lobe
ANS: A

Feedback
A The frontal lobe controls intellectual function, awareness of self, personality, and autonomic responses related to emotion.
B The parietal lobe receives sensory input such as position sense, touch, shape, and texture of objects.
C The thalamus is a relay and integration station from the spinal cord to the cerebral cortex and other parts of the brain.
D The temporal lobe contains the primary auditory cortex. It also interprets auditory, visual, and somatic sensory inputs that are stored in thought and memory.
DIF: Cognitive Level: Understand REF: 337
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

2. In assessing a patient with damage to the occipital lobe, the nurse correlates which clinical manifestation to this injury?
a. Intentional tremors
b. Visual changes
c. Decreased hearing
d. Inability to formulate words
ANS: B

Feedback
A Intentional tremors are caused by cerebellar problems.
B The occipital lobe contains the visual cortex.
C The temporal lobe contains the auditory cortex.
D The ability to formulate words comes from the Broca area in the frontal lobe.
DIF: Cognitive Level: Understand REF: 337
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

3. While obtaining a symptom analysis from a patient who has an inner ear infection, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates vertigo?
a. “I felt lightheaded when I stood up.”
b. “I just could not keep my balance when I sat up.”
c. “It seemed that the room was spinning around.”
d. “I was afraid that I was going to lose consciousness.”
ANS: C

Feedback
A This is a description of dizziness that is often associated with transient ischemia attacks.
B This is a description of disequilibrium, a form of dizziness.
C This report is consistent with vertigo because it includes a sensation of motion.
D This is a description of presyncope, a form of dizziness.
DIF: Cognitive Level: Apply REF: 344-345
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

4. While obtaining a symptom analysis from a patient who had a transient ischemic attack, the nurse helps the patient distinguish between dizziness and vertigo. Which description by the patient indicates dizziness?
a. “I felt lightheaded when I stood up.”
b. “It felt like I was on a merry-go-round.”
c. “The room seemed to be spinning around.”
d. “My body felt like it was revolving and could not stop.”
ANS: A

Feedback
A This is a description of dizziness that is often associated with transient ischemia attacks.
B This report is consistent with objective vertigo because it includes a sensation of motion.
C This report is consistent with objective vertigo because it includes a sensation of motion.
D This report is consistent with subjective vertigo because it includes a sensation of one’s body rotating in space.
DIF: Cognitive Level: Apply REF: 344
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

5. Which patient behavior indicates to the nurse that the patient’s facial cranial nerve (CN VII) is intact?
a. The patient’s eyes move to the left, right, up, down, and obliquely.
b. The patient moistens the lips with the tongue.
c. The sides of the mouth are symmetric when the patient smiles.
d. The patient’s eyelids blink periodically.
ANS: C

Feedback
A This finding represents movement of the extraocular muscles, which are controlled by the oculomotor, trochlear, and abducens cranial nerves (CN III, IV, and VI, respectively).
B This finding represents movement of the tongue, which is controlled by the hypoglossal cranial nerve (CN XII).
C This finding represents facial symmetry, which is controlled by the facial cranial nerve (CN VII).
D This finding represents function of the oculomotor cranial nerve (CN III).
DIF: Cognitive Level: Apply REF: 352-353, Table 15-1
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

6. A nurse assessing a patient who had a cerebrovascular accident involving the Broca area suspects expressive or nonfluent aphasia. What communication abilities does the nurse anticipate from this patient?
a. The patient understands speech but is unable to translate ideas into meaningful speech.
b. The patient is unable to comprehend speech and thus does not respond verbally.
c. The patient is able to understand speech but has difficulty forming words, creating muffled speech.
d. The patient is unable to comprehend speech and responds inappropriately to conversation.
ANS: A

Feedback
A The inability to translate ideas into meaningful speech or writing is termed expressive aphasia or nonfluent aphasia and is associated with lesions in the Broca area in the frontal lobe.
B The inability to comprehend the speech of others is called receptive aphasia or fluent aphasia and is associated with lesions in the Wernicke area in the temporal lobe.
C This speech pattern is more consistent with patients who have involvement of muscles of speech rather than neurologic deficits.
D This speech pattern is not relevant to this patient.
DIF: Cognitive Level: Apply REF: 337| 339| 346
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

7. The nurse hears in a report that a patient has receptive or fluent aphasia. What communication abilities does the nurse anticipate from this patient?
a. The patient understands speech but is unable to translate ideas into meaningful speech.
b. The patient is able to understand speech but has difficulty forming words creating muffled speech.
c. The patient is unable to comprehend speech and thus does not respond verbally.
d. The patient is emotionally liable and cries easily, which interferes with the ability to communicate.
ANS: C

Feedback
A The inability to translate ideas into meaningful speech or writing is termed expressive aphasia or nonfluent aphasia and is associated with lesions in the Broca area in the frontal lobe.
B This speech pattern is more consistent with patients who have involvement of muscles of speech rather than neurologic deficits.
C This deficit is called receptive aphasia or fluent aphasia and is associated with lesions in the Wernicke area in the temporal lobe.
D This speech pattern is not relevant to this patient.
DIF: Cognitive Level: Apply REF: 337| 339| 346
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

8. What is the earliest and most sensitive indication of altered cerebral function?
a. Unequal pupils
b. Loss of deep tendon reflexes
c. Paralysis on one side of the body
d. Change in level of consciousness
ANS: D

Feedback
A Pupillary function represents function of the oculomotor cranial nerve and the midbrain.
B Deep tendon reflexes represent function of the spinal cord and reflex arcs.
C Movement represents function of the spinal cord and posterior frontal lobe.
D Maintaining consciousness represents the functions of and communication between the frontal lobe and reticular activating system.
DIF: Cognitive Level: Remember REF: 347
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

9. A patient reports having difficulty swallowing. Based on this information, how does the nurse assess the cranial nerve related to swallowing?
a. Ask the patient about feeling the blunt end of a paper clip along the jaw line.
b. Observe the rising of the soft palate when the patient says “Ahh.”
c. Observe the symmetry of the face when the patient talks.
d. Assess taste on the anterior part of the tongue.
ANS: B

Feedback
A This tests the sensory function of the trigeminal cranial nerve (CN V).
B This tests the glossopharyngeal cranial nerve (CN IX), which is involved in swallowing. The nurse must correlate difficulty swallowing with the cranial nerves involved with that function and how to test it. The cranial nerves involved are IX, X, and XII.
C This tests the motor function of the facial cranial nerve (CN VII).
D This tests the sensory portion of the facial cranial nerve (CN VII).
DIF: Cognitive Level: Analyze REF: 341| 346| 354
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

10. A patient reports having difficulty swallowing. Based on this information, how does the nurse assess the appropriate cranial nerve?
a. Ask the patient to stick out the tongue and move it in all directions.
b. Ask the patient to move the head to the right and left.
c. Observe the symmetry of the face when the patient talks.
d. Assess for taste on the anterior part of the tongue.
ANS: A

Feedback
A This tests the hypoglossal cranial nerve (CN XII) that is involved in swallowing. The nurse must correlate difficulty swallowing with the cranial nerves involved with that function and how to test them. The cranial nerves involved are IX, X, and XII.
B This tests the function of the spinal accessory cranial nerve (CN XI).
C This tests the motor function of the facial cranial nerve (CN VII).
D This tests the sensory portion of the facial cranial nerve (CN VII).
DIF: Cognitive Level: Analyze REF: 341| 346| 354
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

11. In assessing a patient’s deep tendon reflexes, a nurse finds a patient has a 4+ triceps response. How does the nurse interpret this finding?
a. A hyperactive response
b. A diminished response
c. An absent response
d. An expected response
ANS: A

Feedback
A Deep tendon reflexes are graded from 0 to 4+ and 4+ is a hyperactive response.
B A diminished response is 1+.
C An absent response is 0.
D An expected response is 2+.
DIF: Cognitive Level: Understand REF: 342-343| 349-350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

12. The nurse holds the patient’s relaxed arm with elbow flexed at a 90-degree angle, places a thumb over a tendon in the antecubital fossa, and strikes the thumb with the pointed end of the reflex hammer. Which deep tendon reflex is the nurse assessing?
a. Brachioradialis
b. Biceps
c. Triceps
d. Deltoid
ANS: B

Feedback
A The technique described is not the correct one for assessing the brachioradial deep tendon reflex.
B This is the correct technique for assessing the biceps deep tendon reflex.
C The technique described is not the correct one for assessing the triceps deep tendon reflex.
D There is no reflex to test the deltoid muscle.
DIF: Cognitive Level: Understand REF: 342-343| 349-350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

13. A patient has a compression fracture of the cervical spine at C7 to C8 that is impairing deep tendon reflexes. Which response will the nurse expect from the affected deep tendon reflex?
a. Diminished to absent pronation of the arm
b. Diminished to absent flexion of the elbow
c. Diminished to absent extension of the elbow
d. Diminished to absent adduction of the upper arm
ANS: C

Feedback
A Diminished to absent pronation of the arm is an abnormal response from the brachioradial deep tendon reflex that is innervated from C5 to C6.
B Diminished to absent flexion of the elbow is an abnormal response from the biceps deep tendon reflex that is innervated from C5 to C6.
C Diminished to absent extension of the elbow is an abnormal response from the triceps deep tendon reflex that is innervated from C6, C7, and C8.
D Diminished to absent adduction of the upper arm is not a response of any deep tendon reflex.
DIF: Cognitive Level: Analyze REF: 342-343| 349-350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

14. A nurse holds the patient’s relaxed left arm, with elbow flexed at a 90-degree angle, in one hand. The nurse palpates and then strikes the appropriate tendon just above the elbow with either end of the reflex hammer. What is the expected response for this deep tendon reflex?
a. Flexion of the left elbow
b. Pronation of the left forearm
c. Supination of the left arm
d. Extension of the left elbow
ANS: D

Feedback
A Flexion of the left elbow would be a normal response for the biceps deep tendon reflex.
B Pronation of the left forearm would be a normal response for the brachioradialis deep tendon reflex.
C Supination of the left arm is not a response of any deep tendon reflex.
D Extension of the left elbow is the normal response of the triceps deep tendon reflex.
DIF: Cognitive Level: Analyze REF: 349-350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

15. A nurse holds the patient’s relaxed arm with the elbow flexed at a 90-degree angle, places a thumb over the appropriate tendon in the antecubital fossa, and strikes the thumb with the pointed end of the reflex hammer. What is the expected response for this deep tendon reflex?
a. Flexion of the left elbow
b. Pronation of the left forearm
c. Supination of the left arm
d. Extension of the left elbow
ANS: D

Feedback
A Pronation of the left forearm is a normal response for the brachioradialis deep tendon reflex.
B Supination of the left arm is not a response of any deep tendon reflex.
C Extension of the left elbow is the normal response of the triceps deep tendon reflex.
D Flexion of the left elbow is a normal response for the biceps deep tendon reflex.
DIF: Cognitive Level: Analyze REF: 349-350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

16. How does a nurse test the brachioradial deep tendon reflex?
a. Uses the end of the handle on the reflex hammer to stroke the lateral aspect of the sole of the patient’s foot from heel to ball
b. Asks the patient to slightly pronate the relaxed forearm into the nurse’s hand and strikes the appropriate tendon with the reflex hammer
c. Holds the patient’s relaxed arm with the elbow flexed at a 90-degree angle in one hand, and palpates and strikes the appropriate tendon just above the elbow with the flat end of the reflex hammer
d. Holds the patient’s relaxed arm with the elbow flexed at a 90-degree angle, places a thumb over the appropriate tendon in the antecubital fossa, and strikes the thumb with the pointed end of the reflex hammer
ANS: B

Feedback
A This is the technique to test plantar flexion, the Babinski reflex.
B This is the technique to assess the brachioradial deep tendon reflex.
C This is the technique to test the triceps deep tendon reflex.
D This is the technique to test the biceps deep tendon reflex.
DIF: Cognitive Level: Understand REF: 349-350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

17. A nurse dorsiflexes a patient’s right ankle 90 degrees and then uses a reflex hammer to strike the appropriate tendon. What is the expected response for this deep tendon reflex?
a. Extension of the right lower leg
b. Plantar flexion of the right toes
c. Dorsiflexion of the right foot
d. Plantar flexion of the right foot
ANS: D

Feedback
A This is the expected response for the patellar deep tendon reflex.
B This is the expected response for the plantar reflex (Babinski).
C This is an incorrect response because the nurse is holding the patient’s foot in dorsiflexion, therefore dorsiflexion would not be an expected response.
D Plantar flexion is the expected response of the Achilles deep tendon reflex.
DIF: Cognitive Level: Analyze REF: 349-350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

18. The nurse moves a wisp of cotton lightly across the anterior scalp, paranasal sinuses, and lower jaw to test the function of which cranial nerve?
a. CN IV (trochlear nerve)
b. CN V (trigeminal nerve)
c. CN VI (abducens nerve)
d. CN VII (facial nerve)
ANS: B

Feedback
A The CN IV (trochlear nerve) supplies downward and inward eye movement.
B The CN V (trigeminal cranial nerve) supplies sensation to the cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, and facial skin.
C The CN VI (abducens nerve) supplies lateral eye movement.
D The CN VII (facial nerve) supplies movement of facial expression muscles except the jaw, closes the eyes, and allows labial speech sounds (b, m, w, and rounded vowels).
DIF: Cognitive Level: Understand REF: 341| 352
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

19. A nurse who is assessing a patient’s eyes finds that the pupils are equal, round, and react to light and accommodation (PERRLA). These findings verify the expected functioning of which cranial nerve?
a. Optic cranial nerve (CN II)
b. Oculomotor cranial nerve (CN III)
c. Trochlear cranial nerve (CN IV)
d. Abducens cranial nerve (CN VI)
ANS: B

Feedback
A The optic cranial nerve (CN II) provides vision.
B The oculomotor cranial nerve (CN III) provides these eye functions.
C The trochlear cranial nerve (CN IV) provides eye movement downward and inward.
D The abducens cranial nerve (CN VI) provides lateral eye movement.
DIF: Cognitive Level: Understand REF: 341| 352
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

20. In assessing a patient with a tumor in the pons, the nurse expects to find which abnormalities due to pressure on cranial nerves?
a. Dilated pupils and ptosis
b. Facial asymmetry and impaired hearing
c. Difficulty swallowing
d. Impaired gag reflex
ANS: B

Feedback
A These abnormalities represent pressure on the oculomotor (CN III) that exits from the midbrain.
B These abnormalities represent pressure on the facial and acoustic cranial nerves. The nurse correlates the cranial nerves that exit from the pons which are trigeminal (CN V), abducens (CN VI), facial (CN VII), and acoustic (CN VIII).
C This abnormality represents pressure on the three cranial nerves that affect swallowing: glossopharyngeal (CN IX), vague (CN X), and hypoglossal (CN XII). These cranial nerves exit the brainstem in the medulla oblongata.
D This reflex is controlled by the vagus cranial nerve (CN IX), which exits the brainstem in the medulla oblongata.
DIF: Cognitive Level: Analyze REF: 338| 341| 352, Figure 15-5
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

21. The nurse assesses the glossopharyngeal nerve (CN IX) by testing which reflex?
a. Corneal reflex
b. Gag reflex
c. Blink reflex
d. Cough reflex
ANS: B

Feedback
A The corneal reflex is controlled by the trigeminal cranial nerve (CN V).
B Movement of the posterior pharynx and gag reflex test is controlled by the glossopharyngeal cranial nerve (CN IX).
C The blink reflex is another name for the corneal reflex.
D The cough reflex is controlled from the medulla oblongata.
DIF: Cognitive Level: Understand REF: 341| 354
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

22. Which cranial nerve is assessed when a nurse asks a patient to stick out the tongue and move it side to side?
a. Vagus nerve (CN X)
b. Facial nerve (CN VII)
c. Abducens nerve (CN VI)
d. Hypoglossal nerve (CN XII)
ANS: D

Feedback
A The vagus cranial nerve provides movement for voluntary muscles of phonation (guttural speech sounds) and swallowing.
B The facial cranial nerve provides movement for facial expression muscles except the jaw, closes the eyes, and allows labial speech sounds (b, m, w, and rounded vowels).
C The abducens cranial nerve provides for lateral eye movement.
D The hypoglossal cranial nerve provides tongue movement for speech sound articulation (l, t, n) and swallowing.
DIF: Cognitive Level: Understand REF: 341| 354
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

23. As a patient is walking down the hall, the nurse notices the patient’s staggering, unsteady gait. What findings does the nurse anticipate on the neurologic examination?
a. When the patient stands with feet together, eyes open and then closed, an upright posture is maintained.
b. When the patient touches the end of each finger to the thumb of the same hand, a tremor is observed in the fingers.
c. When the patient is giving a history to the nurse, a tremor is noticed as the patient’s hands rest in the lap.
d. When lying supine, the patient is able to move the heel of one foot down the shin of the other leg.
ANS: B

Feedback
A This is a result of a negative Romberg test. This patient has a cerebellar problem, which would result in a positive Romberg test.
B This patient has a cerebellar problem as evidenced by the staggering gait (noted at the beginning of the encounter) and the intention tremor on movement (noted during the examination).
C This describes a tremor at rest that occurs in patients with parkinsonism rather than with cerebellar problems.
D This describes a normal response on an examination of cerebellar function.
DIF: Cognitive Level: Apply REF: 340| 357-358
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

24. A nurse asks the patient to stand with feet together, arms resting at the sides, with eyes open and then with the eyes closed. Which response by the patient indicates an expected cerebellar function?
a. Sways slightly and maintains upright posture with feet together
b. Is unable to stand upright after turning around in a circle once
c. Steps sideways when standing with feet together and eyes closed
d. Has to move arms horizontally to maintain balance
ANS: A

Feedback
A Maintaining balance indicates function of the cerebellum in the Romberg test.
B Losing balance is an abnormal response, but turning in a circle is not a part of the Romberg test.
C This is an abnormal response for the Romberg test (a positive Romberg test).
D This is an abnormal response for the Romberg test (a positive Romberg test).
DIF: Cognitive Level: Apply REF: 355
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

25. The nurse asks the patient to stand with feet together, arms resting at the sides, with eyes open and then with the eyes closed. Which response by the patient indicates a problem in the cerebellum?
a. Maintains balance when eyes are open, but loses balance with eyes closed
b. Is unable to stand upright after turning around in a circle once
c. Steps sideways when standing with feet together and eyes closed
d. Sways slightly and maintains upright posture with feet together
ANS: C

Feedback
A This is an abnormal response, but is indicative of a proprioceptive problem rather than a cerebellar problem.
B Losing balance is an abnormal response, but turning in a circle is not a part of the Romberg test.
C This is an abnormal response documented as a “positive Romberg” and indicates cerebellar dysfunction.
D This is an expected response documented as a “negative Romberg,” indicating appropriate cerebellar function for balance.
DIF: Cognitive Level: Apply REF: 355
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

26. What is the patient’s expected response when the nurse is assessing graphesthesia?
a. Lies supine and runs one heel along the opposite shin
b. Identifies a familiar object placed in the hands
c. Describes where a sensation of a vibrating tuning fork is felt
d. Identifies a letter or number drawn in the hand
ANS: D

Feedback
A This activity tests cerebellar function of the lower extremities.
B This is a test of stereognosis that tests the function of the parietal lobe and sensory tracts.
C This is a test of vibratory sense that tests sensory tracts.
D This is a test of graphesthesia that assesses the parietal lobe and sensory tracts.
DIF: Cognitive Level: Understand REF: 359-360
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

27. What is the patient’s expected response when the nurse is assessing stereognosis?
a. Identifies an object placed in the hand
b. Distinguishes numbers or letters traced in the palm of the hand
c. Touches the index finger of the nondominant hand to the nose
d. Walks heel to toe in a straight line
ANS: A

Feedback
A A nurse tests stereognosis by asking the patient to close his or her eyes and placing a small, familiar object in the patient’s hand, asking him or her to identify it. Stereognosis tests sensory nerve tracts and parietal lobe function.
B This activity tests graphesthesia, a test of sensory nerve tracts and parietal lobe function.
C This activity tests cerebellar function of the upper extremities.
D This activity tests cerebellar function of the lower extremities.
DIF: Cognitive Level: Understand REF: 337| 359
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

28. A nurse correlates a patient’s altered stereognosis with a neurologic dysfunction in which part of the nervous system?
a. Midbrain or pons
b. Temporal lobe or ascending nerve tracts
c. Frontal lobe or motor nerve tracts
d. Parietal lobe or sensory nerve tracts
ANS: D

Feedback
A Sensory and motor tracts travel though the midbrain and pons, but they are not tested with stereognosis.
B Ascending tracts carry sensory data, but the temporal lobe provides functions of hearing rather than perception of touch.
C Motor tracts carry impulses for movement and they exit from the frontal lobe, which also helps to maintain consciousness.
D A parietal lobe or sensory nerve tract dysfunction prevents a patient from identifying a familiar object by touch, which is a definition of stereognosis.
DIF: Cognitive Level: Apply REF: 337| 359
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

29. Which part of the nervous system is a nurse assessing when he places a vibrating tuning fork on a patient’s wrist or ankle?
a. Frontal lobe and motor tracts
b. Parietal lobe and sensory tracts
c. Hypothalamus and sensory tracts
d. Cerebellum and motor tracts
ANS: B

Feedback
A The frontal lobe sends impulses governing movement through motor (efferent) tracts.
B The parietal lobe receives sensory input, such as vibratory sense and pain, through sensory (afferent) tracts.
C The hypothalamus functions include regulation of body temperature, hunger, and thirst and formation of autonomic nervous system responses.
D The cerebellum provides equilibrium and coordination of movement.
DIF: Cognitive Level: Understand REF: 337| 340| 358-359
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

30. A patient has a herniated disk compressing the lumbar spine at L2, L3, and L4 that is impairing deep tendon reflexes. Which response does a nurse expect from this patient?
a. Diminished contraction of the gastrocnemius muscle with plantar flexion of the foot
b. Diminished contraction of the quadriceps muscle with extension of the lower leg
c. Diminished plantar flexion of the toes
d. Diminished dorsiflexion of the foot and flexion of the toes
ANS: B

Feedback
A This is an abnormal response from the Achilles tendon reflex that is innervated from S1 and S2.
B This is an abnormal response from the patellar deep tendon reflex that is innervated from L2, L3, and L4.
C This is an abnormal response from the plantar reflex or a positive Babinski sign.
D This is an abnormal response of ankle clonus.
DIF: Cognitive Level: Analyze REF: 343| 350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

31. What technique does the nurse use to test the patellar deep tendon reflex?
a. Using the end of the handle on the reflex hammer, the nurse strokes the lateral aspect of the sole of the patient’s foot from heel to ball.
b. Ask the patient to flex one knee to 90 degrees, while the nurse dorsiflexes the ankle and strikes the appropriate tendon on the foot with the flat end of the reflex hammer.
c. Ask the patient to flex one knee to 45 degrees, while the nurse plantar flexes the ankle and strikes the appropriate tendon of the ankle with the pointed end of the reflex hammer.
d. Ask the patient to flex one knee to 90 degrees, while the nurse strikes the appropriate tendon in the knee with the blunt end of the reflex hammer.
ANS: D

Feedback
A This is the technique for testing plantar flex or the Babinski reflex.
B This is the technique for testing the Achilles deep tendon reflex.
C This is not a correct technique for testing any reflex.
D This is the technique for testing the patella deep tendon reflex.
DIF: Cognitive Level: Understand REF: 350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

32. What technique does the nurse use to test ankle clonus?
a. Strokes the lateral aspect of the sole of the patient’s foot from heel to ball with a reflex hammer
b. Supports the patient’s knee in flexed position and sharply dorsiflexes the foot and maintains the flexion
c. Plantar flexes the ankle and strikes the appropriate tendon of the ankle with the hammer
d. Everts the ankle and slowly moves the ankle into plantar flexion and quickly release the foot
ANS: B

Feedback
A This is the technique for testing plantar flex or the Babinski reflex.
B This is the correct technique for assessing ankle clonus.
C This is not a correct technique for testing any reflex.
D This is not a correct technique for testing any reflex.
DIF: Cognitive Level: Understand REF: 350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

33. Which response does a nurse expect when testing ankle clonus of a healthy woman?
a. No movement of the foot
b. Plantar flexion of the foot
c. Extension of the lower leg
d. Dorsiflexion of the foot
ANS: A

Feedback
A No movement of the foot is the expected response from a healthy woman.
B Plantar flexion of the foot is not a response to ankle clonus.
C Extension of the lower leg is not a response to ankle clonus.
D Dorsiflexion of the foot is an abnormal response of ankle clonus.
DIF: Cognitive Level: Understand REF: 350
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

MULTIPLE RESPONSE

1. To complete a symptom analysis, which questions does a nurse ask patient who recently had a seizure for the first time? Select all that apply.
a. “Did you have any warning signs before the seizure started?”
b. “Did you lose consciousness during the seizure?”
c. “Did the room seem to be spinning around before the seizure?”
d. “Did you urinate during the seizure?”
e. “What did you hear while you were seizing?”
f. “How did you feel after the seizure?”
ANS: A, B, D, F
Correct: These are all appropriate questions to ask to gather more data about this patient’s first seizure.
Incorrect: “Did the room seem to be spinning around before the seizure?” This question is about vertigo, which does not relate to this patient. “What did you hear while you were seizing?” The answer to this question is not needed in the data for this patient.

DIF: Cognitive Level: Analyze REF: 345
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

2. Which characteristics are risk factors for cerebrovascular accident? Select all that apply.
a. Excessive alcohol intake
b. Smoking
c. Eating large amounts of smoked foods
d. Obesity
e. Atherosclerosis
f. High blood pressure
ANS: A, B, D, E, F
Correct: All of these are risk factors for cerebrovascular accident.
Incorrect: Eating large amounts of smoked foods is a risk factor for stomach cancer.

DIF: Cognitive Level: Remember REF: 362
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: Potential for Alteration in Body Systems

3. Which manifestations does a nurse correlate with a patient with suspected meningitis? Select all that apply.
a. Ptosis
b. Loss of balance when standing with feet together and the eyes closed
c. Confusion, agitation, and irritability
d. Severe headache
e. Stiff neck
f. Lethargy
ANS: C, D, E, F
Correct: Confusion, agitation, and irritability; severe headache—this is a symptom of meningeal irritation due to inflammation of the meninges; stiff neck; lethargy. Patients may have changes in level of consciousness.
Incorrect: Ptosis is drooping of eyelids controlled by the oculomotor cranial nerve. Loss of balance when standing with feet together and the eyes closed. This describes a positive Romberg test indicating a cerebellar problem.

DIF: Cognitive Level: Understand REF: 362
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems