ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 36 : Introduction to the Nervous System Questions
Question 1 of 5
The nurse scores the client's level of consciousness (LOC) using the Glasgow Coma Scale. Which score should indicate to the nurse that the client needs emergency attention?
Correct Answer: A
Rationale: A score of 9 indicates that the client needs emergency attention. Scores greater than or equal to 11 are considered within normal range.
Question 2 of 5
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?
Correct Answer: D
Rationale: 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.
Question 3 of 5
The nurse is caring for a client with a significant allergy history to various medications and shellfish. Because the client needs to have a diagnostic study with contrast, which medication classification is anticipated?
Correct Answer: B
Rationale: Clients with an allergy history are administered a pretest dose of an antihistamine. Antihistamines block histamine receptors and reduce the manifestations of an allergic reaction. The other options are not administered in the pretest period.
Question 4 of 5
The nurse provides care for a client with a deteriorating neurologic status. The nurse collects data at the beginning of the shift that reveals a falling blood pressure (BP) and heart rate (HR), and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate?
Correct Answer: A
Rationale: The nurse should document flaccidity when the client makes no motor response to stimuli. Clients with impaired cerebral function manifest abnormal posturing, which is documented by the nurse as either decorticate posturing (decorticate rigidity), a position in which the arms are flexed, fists are clenched, and the legs are extended or decerebrate posturing (decerebrate rigidity), when the extremities are stiff and rigid. Muscle tone is documented using a scale of 0 to 5; therefore, weak muscular tone is not the most appropriate documentation.
Question 5 of 5
The nurse collects neurologic data and determines that the client has significant visual deficits. A brain tumor is considered. Which area of the brain does the nurse consider to be most likely to contain the neurologic deficit?
Correct Answer: C
Rationale: The visual receiving area is in the occipital lobe; therefore, this is the area of the brain the nurse determines is affected for the client with significant visual deficits. The frontal lobe contains the written and motor speech areas. The parietal lobe is the primary sensory area of the brain. The temporal lobe is the auditory receiving and association area of the brain, and is responsible for speech comprehension (i.e., Wernicke area).