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 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.
Question 2 of 5
A nurse teaches an 80-year-old client with diminished touch sensation. Which statement should the nurse include in this client's teaching?
Correct Answer: C
Rationale: Older clients with decreased sensation are at risk of injury from the inability to sense changes in terrain when walking. Instructing the client to look at the placement of their feet compensates for this sensory loss and reduces fall risk. Warm water poses a risk of thermal injury, and walking barefoot increases the risk of injury due to lack of protection.
Question 3 of 5
A nurse assesses a client's recent memory. Which client statement confirms that the client's recent memory is intact?
Correct Answer: D
Rationale: Asking clients about recent events that can be verified, such as what they ate for breakfast, assesses recent memory. The other options assess different cognitive functions: making up a rhyme tests higher cognition, recalling birth details tests remote memory, and repeating words tests immediate memory.
Question 4 of 5
A nurse assesses a client who demonstrates a positive Romberg's sign with eyes closed but not with eyes open. Which condition is most likely?
Correct Answer: A
Rationale: A positive Romberg's sign with eyes closed but not with eyes open indicates difficulty with proprioception, as the client relies on vision to compensate for impaired position sense. The other options do not specifically describe this clinical finding.
Question 5 of 5
A nurse asks a client to take deep breaths during an electroencephalography. The client asks, 'Why are you asking me to do this?' How should the nurse respond?
Correct Answer: C
Rationale: Hyperventilation produces cerebral vasoconstriction and alkalosis, which increases the likelihood of seizure activity, enhancing the EEG's ability to detect abnormalities. The other responses are inaccurate regarding the physiological effects of hyperventilation.