ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 65 : Assessment of Neurologic Function Questions
Question 1 of 5
A trauma patient was admitted to the ICU with a brain injury. The patient had a change in level of consciousness, increased vital signs, and became diaphoretic and agitated. The nurse should recognize which of the following syndromes as the most plausible cause of these symptoms?
Correct Answer: C
Rationale: Sympathetic storm, triggered by brain injury, causes altered consciousness, elevated vital signs, diaphoresis, and agitation due to sympathetic overstimulation. Other options do not fully explain these symptoms.
Question 2 of 5
Assessment is crucial to the care of patients with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply.
Correct Answer: B,C,D
Rationale: Accurate neurologic assessment requires understanding diagnostic tests, nursing interventions, and nervous system anatomy. Medication selection and test interpretation are typically physician responsibilities.
Question 3 of 5
When caring for a patient with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would the nurse use to elicit a response from cranial nerve VII?
Correct Answer: C
Rationale: Cranial nerve VII (facial) is assessed by observing facial symmetry during movements like smiling. Trapezius testing assesses XI, whisper tests VIII, and hoarseness tests X.
Question 4 of 5
The nurse is caring for a patient who exhibits abnormal results of the Weber test and Rinne test. The nurse should suspect dysfunction involving what cranial nerve?
Correct Answer: B
Rationale: The Weber and Rinne tests assess hearing, mediated by cranial nerve VIII (acoustic). Trigeminal affects facial sensation, hypoglossal moves the tongue, and trochlear controls eye movement.
Question 5 of 5
The nurse caring for an 80 year-old patient knows that she has a pre-existing history of dulled tactile sensation. The nurse should first consider what possible cause for this patients diminished tactile sensation?
Correct Answer: C
Rationale: Aging reduces sensory receptor density, dulling tactile sensation. Cranial nerve VIII affects hearing, medications may cause other effects, and an old CVA is less likely without evidence.