Chapter 17: Neurological Clinical Assessment and Diagnostic Procedures

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. The breathing pattern of the patient with damage of the mid to lower pons will be altered with respect to:

a.	depth of inspiration.
b.	rhythm of respiration.
c.	length of inspiration and expiration
d.	depth of expiration.

 

ANS:   C

The apneustic and pneumotaxic centers of the pons are responsible for the length of inspiration and expiration and the underlying respiratory rate.

 

DIF:    Cognitive Level: Comprehension       REF:    Table 17-2

OBJ:    Nursing Process: Assessment TOP:    Neurological Clinical Assessment

MSC:   NCLEX: Client Need: Physiological Integrity: Reduction of Risk Potential

 

2. The patient has localized motor function. Which of the following actions would the nurse observe?

a.	The patient reaches with the left hand to stop nail bed pressure on the right index finger.
b.	The patient attempts to withdraw the left foot as it is being subjected to pressure on the left great toe.
c.	The patient has no response to pressure from a sternal rub.
d.	The patient has spontaneous extension responses to pressure on the right index finger.

 

ANS:   A

Localization of motor function occurs when the extremity opposite the one receiving pain crosses the midline of the body in an attempt to remove the noxious stimulus from the affected limb.

 

DIF:    Cognitive Level: Application REF:    Box 17-4

OBJ:    Nursing Process: Assessment TOP:    Neurological Clinical Assessment

MSC:   NCLEX: Client Need: Physiological Integrity: Reduction of Risk Potential

 

3. The patient flexes both arms upward in response to sternal rub. The nurse recognizes that this response is due to a lesion:

a.	above the midbrain, in the region of the thalamus or cerebral hemispheres.
b.	in the sympathetic pathways of the brainstem.
c.	in the vestibular system.
d.	in the cerebellum.

 

ANS:   A

Decortication is manifested by an abnormal flexion response that may occur spontaneously or in response to noxious stimuli. Abnormal flexion occurs with lesions above the midbrain, in the region of the thalamus or cerebral hemispheres.

 

DIF:    Cognitive Level: Comprehension       REF:    344

OBJ:    Nursing Process: Assessment TOP:    Neurological Clinical Assessment

MSC:   NCLEX: Client Need: Physiological Integrity: Reduction of Risk Potential

 

4. The patient fails to respond to either nail bed pressure or sternal rub. The nurse notes this in the patient’s chart as a _____ response.

a.	flaccid
b.	decorticate
c.	decerebrate
d.	localized

 

ANS:   A

Flaccidity is manifested by lack of response to painful stimuli.

 

DIF:    Cognitive Level: Application REF:    Box 17-4

OBJ:    Nursing Process: Assessment TOP:    Neurological Clinical Assessment

MSC:   NCLEX: Client Need: Physiological Integrity: Reduction of Risk Potential

 

5. The nurse reads in the progress notes that the patient has decerebrate posturing. Which of the following actions will the nurse expect to see?

a.	The patient extends both arms downward and outward in response to sternal rub.
b.	The patient flexes both arms and extends both legs in response to painful stimuli.
c.	The patient’s head, neck, and torso spontaneously arch back in a severe spasm.
d.	The patient reacts to painful stimuli by reaching over with the opposite hand to the side where the pain is occurring.

 

ANS:   A

Decerebration is characterized by abnormal extension response, which may occur spontaneously or in response to noxious stimuli.

 

DIF:    Cognitive Level: Analysis      REF:    Box 17-4

OBJ:    Nursing Process: Assessment TOP:    Neurological Clinical Assessment

MSC:   NCLEX: Client Need: Physiological Integrity: Reduction of Risk Potential