ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 36 : Introduction to the Nervous System Questions
Question 1 of 5
A critical care nurse is documenting the assessment of a client. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. This means that the client:
Correct Answer: B
Rationale: Flaccidity is when the client has no motor response to stimuli. Flaccidity is a motor assessment.
Question 2 of 5
A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult that is slowing transmission of the motor neurons, in what would the nurse anticipate a delayed reaction?
Correct Answer: D
Rationale: The central nervous system is composed of the brain and the spinal cord. Motor neurons transmit impulses from the central nervous system. Slowing transmission in this area would slow the response of transmission leading to a delay in reaction. Sensory neurons transmit impulses from the environment to the central nervous system, allowing identification of a stimulus. Cognitive centers of the brain interpret the information.
Question 3 of 5
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:
Correct Answer: B
Rationale: 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.
Question 4 of 5
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 which cranial nerve?
Correct Answer: C
Rationale: 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.
Question 5 of 5
The nurse is caring for a client in the emergency department with a diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the client's face and torso. Which action by the nurse aide would prompt the nurse to provide further instruction?
Correct Answer: B
Rationale: Further instruction would be provided to the nurse aide when the nurse aide attempted to move the client's head to clean behind the ears. There should be no movement of the client's head when there is a history of head trauma. Cleaning the client's face with soapy water, cleaning the eye area, and cleaning the neck and upper chest are all appropriate actions completed by the nurse aide.