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 nurse is noting from a client's neurologic assessment findings that the client's motor impulses are interrupted from the brain to the spinal cord. It also appears that the client lacks sensory impulses from the peripheral sensory neurons to the brain. Which area has the deficit?
Correct Answer: B
Rationale: The medulla oblongata lies below the pons and transmits motor impulses from the brain to the spinal cord, and sensory impulses from the peripheral sensory neurons to the brain. The pons is part of the brainstem. The midbrain forms the forward part of the brainstem and connects the pons and the cerebellum with the two cerebral hemispheres. The subarachnoid space lies between the pie matter and the arachnoids membrane.
Question 2 of 5
A nurse is working in a neurologist's office. The physician orders a Romberg test. What should the nurse instruct the client to do?
Correct Answer: B
Rationale: 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.
Question 3 of 5
The nurse is caring for a client newly diagnosed with multiple sclerosis who is overwhelmed by learning about the disease. The client indicates understanding that there is a disruption in the covering of axons but does not remember what the covering is called. What should the nurse tell the client?
Correct Answer: C
Rationale: Myelin is a fatty substance that covers some axons in the CNS and PNS. The nurse would be most correct in answering the question and then, if the client is tired, following up at the next meeting. It would also be appropriate to provide literature for the client to review at leisure. Discounting the client's need to know information about the disease process is belittling. Telling the client that more research needs to be done discounts the valuable information which is known.
Question 4 of 5
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, what does the nurse anticipate the liver will do?
Correct Answer: B
Rationale: When the body is under stress, the sympathetic nervous system is activated to ready the body for action. The effect of the body is to mobilize stored glycogen to glucose to provide additional energy for body action.
Question 5 of 5
The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?
Correct Answer: C
Rationale: The neck is examined for stiffness or abnormal position. The presence of rigidity is assessed by moving the head and chin toward the chest. The nurse should not maneuver the neck if a head or neck injury is suspected or known. The neck should also not be maneuvered if trauma to any part of the body is evident. Moving the head toward the sides or pressing the bones on the neck will not help assess for neck rigidity correctly. While assessing for neck rigidity, sensation at the neck area is not assessed.