ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 41 : Assessment of the Nervous System Questions
Question 1 of 5
A nurse assesses a client with a brain tumor. Which newly identified assessment findings should alert the nurse to urgently communicate with the health care provider? (Select all that apply.)
Correct Answer: A,B,C,D
Rationale: Changes in Glasgow Coma Scale score, abnormal posturing, altered cognition or speech, and nonreactive pupils indicate neurological deterioration, requiring urgent provider notification. Stable vital signs do not necessitate immediate action.
Question 2 of 5
A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodine-based contrast. Which actions should the nurse take to prepare the client for this procedure? (Select all that apply.)
Correct Answer: A,B,C
Rationale: Asking about allergies (especially to iodine or shellfish), evaluating renal function, and ensuring informed consent are critical to safely administer iodine-based contrast. Assessing breath sounds or hematocrit/hemoglobin is unrelated to CT preparation.
Question 3 of 5
A nurse assesses an older client. Which assessment findings should the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.)
Correct Answer: B,E
Rationale: Normal
Question 4 of 5
A nurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which action should the nurse perform when educating this client about newly prescribed medications?
Correct Answer: C
Rationale: The temporal lobe contains the auditory center for sound interpretation. The client's hearing will be impaired in the left ear. The nurse should sit on the client's right side and speak into the right ear to compensate for the hearing impairment caused by left temporal lobe damage. The other interventions do not directly address the hearing deficit associated with this condition.
Question 5 of 5
A nurse plans care for a client who has a hypoactive response to a test of deep tendon reflexes. Which intervention should the nurse include in this client's plan of care?
Correct Answer: B
Rationale: Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. Providing ambulation assistance helps prevent injury by ensuring the client has support while walking. The other interventions do not address the balance and coordination issues caused by hypoactive reflexes.