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Medical Surgical Nursing in Canada 1st Edition Lewis Test Bank

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Medical Surgical Nursing in Canada 1st Edition Lewis Test Bank

  • ISBN-10:0779699696
  • ISBN-13:978-0779699698

 

 

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Medical Surgical Nursing in Canada 1st Edition Lewis Test Bank

  • ISBN-10:0779699696
  • ISBN-13:978-0779699698

 

 

 

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Below you will find some free nursing test bank questions from this test bank:

Lewis: Medical Surgical Nursing in Canada

 

Test Bank

 

Chapter 54: Nursing Assessment: Nervous System

 

  MULTIPLE CHOICE

 

  1.      A client with a deep, large laceration of the left forearm, which has damaged nerve fibres as well as other tissue, asks the nurse to explain what the effect of the nerve damage will be. What is the nurse’s best response to Mr. Taylor?
1. Nerve cells cannot regenerate and the sensory and motor loss will be permanent.
2. He will probably have return of normal motor and sensory function because peripheral nerve cells can regenerate.
3. Only nerve fibres within the central nervous system are capable of regeneration and the nerve loss he has distal to his injury will be permanent.
4. There is a chance that some nervous function will return because peripheral nerve fibres can slowly regenerate if cell bodies have not been damaged.

 

 

ANS:   4                      PTS:    1                      DIF:    Cognitive Level: Comprehension

REF:    Text Reference: pp. 1473, 1480         TOP:    Nursing Process: Implementation

 

  1.      Pain impulses are believed to be transmitted by fine, myelinated A-delta fibres and unmyelinated C fibres. Based on knowledge of nerve transmission, what does the nurse recognize that pain impulses carried by the myelinated A-delta fibres result in?
1. Faster transmission than impulses carried by unmyelinated C fibres
2. Slower onset and speed of transmission than impulses carried by unmyelinated C fibres
3. Depolarization of the A-delta fibres occurring in a wave carried throughout the entire length of the axon
4. Earlier perception of the sensory input because myelinated afferent fibres do not synapse before reaching the brain

 

 

ANS:   1                      PTS:    1                      DIF:    Cognitive Level: Comprehension

REF:    Text Reference: p. 1472                     TOP:    Nursing Process: Assessment

 

  1.      When the nurse administers a drug that increases the synaptic release of gamma-aminobutyric acid (GABA), what is the effect the nurse would expect?
1. Decreased nervous system function in all body processes
2. An inhibitory effect on the transmission of an action potential
3. An increased likelihood that an action potential will be generated
4. Excitation of nerve cells with pronounced activity of the cells affected

 

 

ANS:   2                      PTS:    1                      DIF:    Cognitive Level: Application

REF:    Text Reference: p. 1475                     TOP:    Nursing Process: Diagnosis

 

  1.      In a client who has lost voluntary muscle control of her left leg, the nurse recognizes that which spinal pathway may be affected?
1. Corticospinal tract 3. Spinothalamic tract
2. Corticobulbar tract 4. Spinocerebellar tract

 

 

ANS:   1                      PTS:    1                      DIF:    Cognitive Level: Comprehension

REF:    Text Reference: p. 1476                     TOP:    Nursing Process: Assessment

 

  1.      A client has a lesion that affects lower motor neurons. During assessment of the client’s lower extremities, what does the nurse expect to find?
1. Spasticity 3. Hyperreflexia
2. Flaccidity 4. Loss of sensation

 

 

ANS:   2                      PTS:    1                      DIF:    Cognitive Level: Application

REF:    Text Reference: p. 1476                     TOP:    Nursing Process: Assessment

 

  1.      Which of the following assessment findings would be expected by the nurse when examining a client with a lesion of the left posterior temporal lobe?
1. Inability to reason or problem solve
2. Loss of sensation on the left side of the body
3. Inability to comprehend written or oral language
4. Inability to voluntarily move the right side of the body

 

 

ANS:   3                      PTS:    1                      DIF:    Cognitive Level: Comprehension

REF:    Text Reference: p. 1477                     TOP:    Nursing Process: Assessment

 

  1.      An adrenergic blocking agent that inhibits sympathetic nervous system activity is prescribed for a client. Based on knowledge of the effects of the sympathetic nervous system, the nurse teaches the client that which of the following side effects may occur?
1. Dry mouth 3. Slowed pulse
2. Constipation 4. Urinary retention

 

 

ANS:   3                      PTS:    1                      DIF:    Cognitive Level: Application

REF:    Text Reference: pp. 1481–1482         TOP:    Nursing Process: Implementation

 

  1.      When obtaining a health history from a client with a neurological problem, the nurse is likely to elicit the most valid response from the client by asking the client which of the following questions?
1. “Do you ever have any nausea or dizziness?”
2. “Does the pain radiate from your back into your legs?”
3. “Do you have any sensations of pins and needles in your feet?”
4. “Can you describe the sensations you are having in your chest?”

 

 

ANS:   4                      PTS:    1                      DIF:    Cognitive Level: Application

REF:    Text Reference: pp. 1485–1486         TOP:    Nursing Process: Assessment

 

  1.      When discussing the client’s elimination health pattern during assessment of a client with a neurological problem, the nurse asks how the client deals with identified incontinence. Which of the following rationales is used by the nurse for questioning the client’s method of dealing with this problem?
1. Motivation and ability to care for one’s self can be identified.
2. Drugs used to control incontinence may alter neurological function.
3. Assessment of the client’s ability to cope with stress can be made.
4. The response reveals the client’s cognitive ability to problem solve.

 

 

ANS:   4                      PTS:    1                      DIF:    Cognitive Level: Application

REF:    Text Reference: pp. 1486–1487         TOP:    Nursing Process: Assessment

 

  1.    A 71-year-old client reports a change in sleep patterns occurring over the past two to three years. Based on knowledge of the effects of aging on the reticular activating system, what would the nurse expect the client to exhibit?
1. Increased rapid eye movement (REM) sleep
2. Longer cycles of sleep
3. Increased sleep apnea
4. Increased spontaneous awakening

 

 

ANS:   4                      PTS:    1                      DIF:    Cognitive Level: Application

REF:    Text Reference: p. 1478                     TOP:    Nursing Process: Assessment

 

  1.    To assess the functioning of the optic nerve (CN II), what should the nurse do?
1. Apply a cotton wisp strand to the cornea.
2. Perform a confrontational test for visual fields.
3. Evaluate pupil response to light and accommodation.
4. Ask the client to follow a finger with the eyes as it is moved vertically, horizontally, and diagonally.

 

 

ANS:   2                      PTS:    1                      DIF:    Cognitive Level: Comprehension

REF:    Text Reference: pp. 1488–1489         TOP:    Nursing Process: Assessment

 

  1.    Neurological testing of the client by the nurse indicates impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). Based on these findings, what should the nurse plan to do?
1. Insert an oral airway.
2. Withhold oral fluid or foods.
3. Provide highly seasoned foods.
4. Apply artificial tears to protect the cornea.

 

 

ANS:   2                      PTS:    1                      DIF:    Cognitive Level: Application

REF:    Text Reference: pp. 1481, 1489         TOP:    Nursing Process: Implementation

 

  1.    The nurse determines through neurological testing that a client has bilateral sensory and motor impairment of both lower limbs. What is the most important value of this information to the nurse?
1. To plan care to protect the client from injury
2. To contribute to the medical diagnosis of the client
3. To anticipate other neurological deficits that could arise
4. To provide a baseline assessment against which to evaluate changes in function

 

 

ANS:   1                      PTS:    1                      DIF:    Cognitive Level: Application

REF:    Text Reference: pp. 1486, 1490–1491

TOP:    Nursing Process: Implementation

 

  1.    During somatic sensory examination for pain, temperature, and touch, what should the nurse do?
1. Test from distal to proximal areas.
2. Ask the client to close his or her eyes.
3. Warn the client that he or she is about to be touched.
4. Apply the stimulus in a systematic, rhythmic manner.

 

 

ANS:   2                      PTS:    1                      DIF:    Cognitive Level: Comprehension

REF:    Text Reference: p. 1490                     TOP:    Nursing Process: Implementation

 

  1.    To prepare a client who is to have a lumbar puncture performed for analysis of cerebrospinal fluid, what should the nurse inform him about?
1. He will be given a mild sedative to help control muscle spasms.
2. He should cough as soon as he feels the needle enter the spinal canal.
3. He may be required to lie flat on his back for 24 hours following the test.
4. He will be positioned on his side with his knees drawn to the chest and his head flexed to the chest.

 

 

ANS:   4                      PTS:    1                      DIF:    Cognitive Level: Comprehension

REF:    Text Reference: pp. 1493, 1495         TOP:    Nursing Process: Implementation

 

  1.    When reviewing the results of a client’s cerebrospinal fluid analysis obtained from a lumbar puncture, which of the following does the nurse identify as abnormal?
1. pH of 7.35
2. White blood cell (WBC) count: 4/L (0.004/L)
3. Protein: 0.30 g/L (30 mg/dL)
4. Glucose: 1.7 mmol/L (30 mg/dL)

 

 

ANS:   4                      PTS:    1                      DIF:    Cognitive Level: Comprehension

REF:    Text Reference: p. 1495                     TOP:    Nursing Process: Assessment

 

  1.    A client is scheduled for a myelograph to confirm the presence of a herniated intervertebral disk. What is an appropriate nursing intervention with respect to this diagnostic test?
1. Obtain an allergy history prior to the test.
2. Position the client in a flat position 24 hours following the test.
3. Keep the client on nothing by mouth (NPO) for six to eight hours following the test.
4. Warn the client that paralysis could result from injection of the contrast medium.

 

 

ANS:   1                      PTS:    1                      DIF:    Cognitive Level: Comprehension

REF:    Text Reference: p. 1496                     TOP:    Nursing Process: Implementation

 

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