a.
Flexion of the hand
b.
Pronation of the hand
c.
Flexion of the forearm
d.
Extension of the forearm
32. The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side
of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes.
How should the nurse document this finding?
a.
Positive Babinski sign
b.
Plantar reflex abnormal
c.
Plantar reflex present
d.
Plantar reflex 2+ on a scale from “0 to 4+”
33. In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise or
stimulation. The mother reports that in the last week he has been sleeping all of the time, and
when he is awake all he does is cry. The nurse hears that the infant’s cries are very high
pitched and shrill. What is the most appropriate response by the nurse?
a.
Refer the infant for further testing.
b.
Talk with the mother about eating habits.
c.
Do nothing; these are expected findings for an infant this age.
d.
Tell the mother to bring the baby back in 1 week for a recheck.
34. Which of these tests would the nurse use to check the motor coordination of an 11-month-old
infant?
a.
Denver II
b.
Stereognosis
c.
Deep tendon reflexes
d.
Rapid alternating movements
35. To assess the head control of a 4-month-old infant, the nurse lifts up the infant in a prone
position while supporting his chest. The nurse looks for what normal response?
a.
Infant raises the head and arches the back.
b.
Infant extends the arms and drops down the head.
c.
Infant flexes the knees and elbows with the back straight.
d.
Infant holds the head at 45 degrees and keeps the back straight.
36. While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following
response: abduction and flexion of the arms and legs; fanning of the fingers, and curling of the
index finger and thumb in a C position, followed by the infant bringing in the arms and legs to
the body. What does the nurse recall about this response?
a.
This response could indicate brachial nerve palsy.
b.
This reaction is an expected startle response at this age.
c.
This reflex should have disappeared between 1 and 4 months of age.
d.
This response is normal as long as the movements are bilaterally symmetric.
37. To test for gross motor skill and coordination of a 6-year-old child, which of these techniques
would be appropriate?
a.
Have the child hop on one foot.
b.
Have the child stand on his head.
c.
Ask the child to touch his finger to his nose.
d.
Ask the child to make “funny” faces at the nurse.
38. During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors
when he reaches for something and his head is always nodding. No associated rigidity is
observed with movement. Which of these statements is most accurate?
a.
These findings are normal, resulting from aging.
b.
These findings could be r/t hyperthyroidism.
c.
These findings are the result of Parkinson disease.
d.
This patient should be evaluated for a cerebellar lesion.
39. While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3
days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. What does this
finding indicate?
a.
Great sense of humor
b.
Uncooperative behavior
c.
Decreased level of consciousness
d.
Inability to understand questions
40. The nurse is caring for a patient who has just had neurosurgery. To assess for increased
intracranial pressure, what would the nurse include in the assessment?
a.
CNs, motor function, and sensory function
b.
Deep tendon reflexes, vital signs, and coordinated movements
c.
Level of consciousness, motor function, pupillary response, and vital signs
d.
Mental status, deep tendon reflexes, sensory function, and pupillary response
41. During an assessment of a 22-year-old woman who sustained a head injury from an
automobile accident 4 hours earlier, the nurse notices the following changes: pupils were
equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and
reacts to light. What do these findings suggest?
a.
Injury to the O.D.
b.
Test inaccurately performed
c.
Increased intracranial pressure
d.
Normal response after a head injury
42. A 32-year-old woman tells the nurse that she has noticed “very sudden, jerky movements”
mainly in her hands and arms. She says, “They seem to come and go, primarily when I am
trying to do something. I haven’t noticed them when I’m sleeping.” What do these symptoms
suggest?
a.
Tics
b.
Chorea
c.
Athetosis
d.
Myoclonus
43. During an assessment of a 62-year-old man, the nurse notices the patient has a stooped
posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger
movements. What do these findings suggest?
a.
Parkinsonism
b.
Cerebral palsy
c.
Cerebellar ataxia
d.
Muscular dystrophy
44. During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that
the patient responds to pain by extending, adducting, and internally rotating his arms. His
palms pronate, and his lower extremities extend with plantar flexion. Which statement
concerning these findings is most accurate? What do these findings indicate?
a.
A lesion of the cerebral cortex
b.
A completely nonfunctional brainstem
c.
Normal findings that will resolve in 24 to 48 hours
d.
A very ominous sign and may indicate brainstem injury
45. A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he
walks, his left arm is immobile against the body with flexion of the shoulder, elbow, wrist,
and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts
with each step. What type of gait disturbance is this individual experiencing?
a.
Scissors gait
b.
Cerebellar ataxia
c.
Parkinsonian gait
d.
Spastic hemiparesis
46. In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of
these physical assessment findings should the nurse expect?
a.
Hyperreflexia
b.
Fasciculations
c.
Loss of muscle tone and flaccidity
d.
Atrophy and wasting of the muscles
47. A 59-year-old patient has a herniated intervertebral disk. Which of the following findings
should the nurse expect to see on physical assessment of this individual?
a.
Hyporeflexia
b.
Increased muscle tone
c.
Positive Babinski sign
d.
Presence of pathologic reflexes
48. A patient is unable to perform rapid alternating movements such as rapidly patting her knees.
How should the nurse document this finding?
a.
Ataxia
b.
Astereognosis
c.
Loss of kinesthesia
d.
Presence of dysdiadochokinesia
49. The nurse should test the functioning of which structure(s) when determining whether a
person is oriented to his or her surroundings?
a.
Cerebellum
b.
Cranial nerves
c.
Cerebral cortex
d.
Medulla oblongata
50. During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which
conclusion by the nurse is correct?
a.
A normal occurrence
b.
Indicates disease of the cerebellum or brainstem
c.
A sign that the patient is nervous about the examination
d.
Indicates a visual problem, and a referral to an ophthalmologist is indicated
51. What does testing kinesthesia assess?
a.
Fine touch
b.
Position sense
c.
Motor coordination
d.
Perception of vibration
52. The nurse is reviewing a patient’s medical record and notes that he is in a coma. Using the
Glasgow Coma Scale, which number indicates that the patient is in a coma?
a.
6
b.
12
c.
15
d.
24
53. A man who was found wandering in a park at 2 AM has been brought to the emergency
department for an examination; he said he fell and hit his head. During the examination, the
nurse asks him to use his index finger to touch the nurse’s finger, then his own nose, then the
nurse’s finger again (which has been moved to a different location). The patient is clumsy,
unable to follow the instructions, and overshoots the mark, missing the finger. What does the
nurse suspect?
a.
Cerebral injury
b.
Peripheral neuropathy
c.
Cerebrovascular accident
d.
Acute alcohol intoxication
54. The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor.
With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the
foot and inward, across the ball of the foot. In response, the patient’s toes fan out, and the big
toe shows dorsiflexion. How should the nurse interpret these findings?
a.
Clonus, which is a hyperactive response
b.
Achilles reflex, which is an expected response
c.
Negative Babinski sign, which is normal for adults
d.
Positive Babinski sign, which is abnormal for adults
MULTIPLE RESPONSE
1. A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he
is getting more and more confused. He laughs when he is found to be forgetful, saying “I’m
just getting old!” After the nurse completes a thorough neurologic assessment, which findings
would be indicative of Alzheimer disease? (Select all that apply.)
a.
Getting lost in one’s own neighborhood
b.
Occasionally forgetting names or appointments
c.
Sometimes having trouble finding the right word
d.
Misplacing items, such as putting dish soap in the refrigerator
e.
Difficulty performing familiar tasks, such as placing a telephone call
f.
Rapid mood swings, from calm to tears, for no apparent reason.
COMPLETION
1. During the assessment of deep tendon reflexes, the nurse finds that a patient’s responses are
bilaterally normal. What number is used to indicate normal deep tendon reflexes when the
documenting this finding? ____+Correct.
