Nursing Management: Chapter 21, The Neurologic System

Question 1 of 9

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When assessing a patient with a brain tumor, which early assessment finding would the nurse associate with increasing intracranial pressure (ICP)?

• Correct
  • Decreasing level of consciousness (LOC)LOC is generally the earliest indicator of increasing ICP and is evaluated by assessing the patient for changes in responsiveness.
• • Elevated temperatureAlthough indicative of other central nervous system disorders, usually of the hypothalamus or infectious processes, increasing temperature is generally not helpful when evaluating signs and symptoms of increasing ICP.
• • Agitation and hostilityAssessing the patient for changes in cooperativeness or mood is also significant, but LOC is more sensitive and occurs earlier.
• • Increasing blood pressureWidening pulse pressure (the difference between the systolic and diastolic readings), not just increasing blood pressure, is a better sign of increasing ICP.

Question 2 of 9

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Which diagnostic test would the nurse anticipate scheduling for a patient suspected of having meningitis? Select all that apply. One, some, or all responses may be correct.

• • MyelographyMyelography detects spinal lesions, intervertebral disk problems, tumors, and cysts.
• Correct
  • Lumbar punctureA lumbar puncture would be used to test for neurologic infection, such as meningitis.
• • ElectromyographyElectromyography measures the electrical activity of skeletal muscles.
• • ElectroencephalographyElectroencephalography is used to detect abnormal brain wave patterns.
• Correct
  • Cerebrospinal fluid analysis and cultureA cerebrospinal fluid analysis and culture would be used to test for neurologic infection, such as meningitis.

Question 3 of 9

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Which parameter would the nurse associate with the Glasgow Coma Scale? Select all that apply. One, some, or all responses may be correct.

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  • A score of 8 or less indicates coma level.A score of 8 or less indicates coma level.
• • A score of 0 indicates a totally comatose patient.A score of 0 does not exist in the Glasgow Coma Scale.
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  • A score of 3 indicates a totally comatose patient.A score of 3 indicates a totally comatose patient.
• Correct
  • The optimal score is 15, which indicates a fully alert patient.The optimal score of the Glasgow Coma Scale is 15, which indicates a fully alert patient.
• • The optimal score is 100, which indicates a fully alert patient.A score of 100 does not exist in the Glasgow Coma Scale.

Question 4 of 9

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What Glasgow Coma Scale score would the nurse assign to a patient who opens their eyes to sound, elicits motor responses to localized pain, and has some inappropriate words during conversation?

• • 8Opening eyes to sound = 3, motor response to localized pain = 5, and using inappropriate words in verbal response = 3. Total score = 11
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  • 11Opening eyes to sound = 3, motor response to localized pain = 5, and using inappropriate words in verbal response = 3. Total score = 11
• • 14Opening eyes to sound = 3, motor response to localized pain = 5, and using inappropriate words in verbal response = 3. Total score = 11
• • 9Opening eyes to sound = 3, motor response to localized pain = 5, and using inappropriate words in verbal response = 3. Total score = 11

Question 5 of 9

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Which Full Outline of UnResponsiveness (FOUR) score would the nurse assign to a patient whose eyelids are closed, but open to loud voice, has a flexion motor response to pain, one pupil is wide is fixed, and is not intubated but demonstrated irregular breathing?

• • 7Eyelids closed, but open to loud voice = 2, flexion response to pain = 2, one pupil wide and fixed = 3, and not intubated, but irregular breathing = 2. Total score = 9. A score of 7 may occur if eyes do not open (0).
• • 8Eyelids closed, but open to loud voice = 2, flexion response to pain = 2, one pupil wide and fixed = 3, and not intubated, but irregular breathing = 2. Total score = 9. A score of 8 may occur if response to pain is close to normal (3).
• Correct
  • 9Eyelids closed, but open to loud voice = 2, flexion response to pain = 2, one pupil wide and fixed = 3, and not intubated, but irregular breathing = 2. Total score = 9
• • 10Eyelids closed, but open to loud voice = 2, flexion response to pain = 2, one pupil wide and fixed = 3, and not intubated, but irregular breathing = 2. Total score = 9. A score of 10 may occur if all but one area are normal and receive scores of 4.

Question 6 of 9

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The nurse understands the Full Outline of UnResponsiveness (FOUR) score includes which category?

• • Cardiac functionCardiac function is not included in the FOUR score scale assessment categories.
• • Confused conversationThe Glasgow Coma Scale (GCS) includes verbal response; however, since FOUR score is used for nonresponsive, intubated patients, it does not include scoring of patient verbal response.
• • Incomprehensible soundsIncomprehensible sounds is categorized under the GCS area of verbal response. FOUR score does not include evaluation of verbal response.
• Correct
  • BrainstemThe FOUR score does include eye, motor, brainstem, and respiratory.

Question 7 of 9

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Which of the following neurologic assessments should the nurse perform during the patient’s activities of daily living? Select all that apply. One, some, or all responses may be correct.

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  • BalanceIt would be important to assess whether the patient is having any difficulty with balance.
• Correct
  • Face symmetryThe nurse should assess whether the face moves symmetrically when the patient smiles.
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  • SpeechThe nurse should assess whether the patient’s speech is clear when answering questions.
• • Bowel incontinenceBowel incontinence would be part of a genitourinary assessment.
• Correct
  • Pupil sizePupils should be equal in size and should constrict and dilate readily when the environmental light changes.
• Correct
  • Level of alertnessThe nurse should assess whether the patient has the usual level of alertness.

Question 8 of 9

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Which statement made by the nurse demonstrates an understanding of an electroencephalography (EEG)?

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  • “The EEG detects electrical activity in the brain.”This is a correct, as the EEG is done to test for abnormal brain patterns.
• • “Taking a sleeping pill the night before will help the patient be well rested for the test.”No sedatives or sleeping pills should be taken the night before the EEG. This will interfere with the integrity of the test’s results.
• • “Caffeine should held for 8 hours prior to the EEG.”Caffeine should be held 24 to 48 hours prior to an EEG.
• • “When the patient has a sleep EEG ordered, it is important to keep the NPO the night before the test.”If a sleep EEG is ordered, the patient will need to stay awake most of the night prior to the EEG; however, NPO is contraindicated because it can cause hypoglycemia, which can affect the test.

Question 9 of 9

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What is the best way for the nurse to test the trigeminal cranial nerve?

• • Ask the patient to smile and frown.This is a good way to assess the facial nerve.
• • Whisper from behind the patient and ask them to identify what was said.This is a good way to assess the vestibulocochlear nerve.
• Correct
  • Ask the patient to clamp the jaw shut and open mouth against resistance.This is a good way to assess the trigeminal nerve.
• • Ask the patient to open the mouth wide, stick out tongue, and say “Ah.”This is a good way to assess the glossopharyngeal nerve.