What structures are located in the brain stem? (SATA)

medulla oblongata, Midbrain, pons

A pt with lack of O2 to his heart will have pain in his chest and possibly in his shoulders, arms, or jaw. Explaination?

The sensory cortex does not have the ability to localize pain in the heart

Health hx of pt w/ seizures, the nurse assesses whether pt has an aura. What is best question for obtaining info?

Do you have any warning signs before your seizure starts?

A patient has a serered spinal nerve d/t trauma. Which statement is true in this situation?

Adjacent spinal nerves will continue to carry sensations for the dermatome

22 yo w/head injury from auto accident 4 hrs ago has pupils were equal but right pupil is fully dilated and nonreactive

Findings suggest increased intracranial pressure

1 mo old lack of response to noise or stimulation, sleeping all the time, does not cry Cries are high pitched and shrill

Nurse should refer the infant for further testing

What does the frontal lobe control? (SATA)

Emotions, Behavior, Personality, Intellectual function, Motor Speech

Which of these statements about the peripheral nervous system is correct?

It carries input to the CNS by afferent fibers and away by efferent fibers

Pt has just had neurosurgery. To assess for ICP, what would the nurse include in assessment?

LOC, motor function, pupillary response, and vital signs.

CN assessment finds: asymmetry when pt smiles or frowns, uneven lifting of eyebrows, sagging of lower lids.

Indicate dysfunction of motor component of CN VII

Pt w/ CVA, arm is immobile against body when walking, flexion of shoulder, elbow, wrist, and adduction of shoulder

Type of gait disturbance = Spastic hemiparesis

Testing deep tendon reflexes. When striking Achilles heel & quadricep muscle, unable to elicit a reflex. Next response?

Ask the pt to lock fingers and pull.

Recent HI responds to pain by extending, adducting, and internally rotating arms, palms pronate, LE extend plantar flexi

Pt response is omnous sign and may indicate brain stem injury

Testing fx of CN XI. Which statement best describes the response expected if nerve intact?

Moves the head and shoulders against resistance with equal strength.

62 yo has a stooping posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movement

Finding consistent with Parkinsonism

To assess head control of 4 mo old, the nurse lifts up the infant in prone position while supporting chest. Normal respo

Raises the head, and arches the back

Superficial reflexes on adult. When stoking up lateral side of sole of foot and across ball, plantar flexion of the toes

Document plantar reflex present

Health hx of 74 yo, he drinks alcohol daily and he has tremor in hands that affects ability to hold things. Response?

Does the tremor change when you drink alcohol?

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HA Chapter 24 Jarvis

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Chapter 24 Jarvis Health Assessment

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Questions 80

Answers

1
59 yo pt w/ herniated intervertebral disk. Which finding should nurse expect to see on physical assessment?
Positive Babinski sign
Hyporeflexia
Increased muscle tone
Presence of pathologic reflexes
2
What structures are located in the brain stem? (SATA)
medulla oblongata
basal ganglia
Pituitary gland
Midbrain
Thalamus
pons
3
A pt with lack of O2 to his heart will have pain in his chest and possibly in his shoulders, arms, or jaw. Explaination?
The sensory cortex does not have the ability to localize pain in the heart
Because of lack of O2 in heart will have pain in chest, shoulders, arms/jaw
A lesion had developed in the dorsal root, preventing sensation transmissio
A problem exists w/sensory cortex and its ability to discriminate location
4
Health hx of 3 mo old from mother, nurse asks about ability to suck and grasp the mother's finger. What is she assessing
Cerebral cortex function
Intelligence
Reflexes
CNs
5
Health hx of pt w/ seizures, the nurse assesses whether pt has an aura. What is best question for obtaining info?
After a seizure, do you spend a lot of time sleeping?
Do you experience any color change or incontinence during seizure?
Do you have any warning signs before your seizure starts?
Does your muscle tone seem tense or limp?
6
Which cranial nerve controls facial movements?
II
V
VII
IV
7
What are the parts of the nervous system?
Motor & Sensory
Peripheral & Autonomic
Hypothalamus & Cerebral
Central & Peripheral
8
The ability that humans have to perform very skilled movements such as writing is controlled by the?
Basal ganglia
Spinothalamic tract
Corticospinal tract
Extropyramidal tract
9
A patient has a serered spinal nerve d/t trauma. Which statement is true in this situation?
Because there are 31 pairs, no effect result if only one nerve severed
Only affect motor fx of pt because spinal nerves have no sensory component.
The dermatome served by this nerve will no longer experience any sensation
Adjacent spinal nerves will continue to carry sensations for the dermatome
10
What part of the brain is responsible for language comprehension?
Broca's area
Postcentral gyrus
Wernicke's area
Medulla Oblongata
11
22 yo w/head injury from auto accident 4 hrs ago has pupils were equal but right pupil is fully dilated and nonreactive
Findings suggest increased intracranial pressure
Findings suggest Injury to right eye
Findings suggest normal response to head injury
Finding suggest test inaccurately performed
12
1 mo old lack of response to noise or stimulation, sleeping all the time, does not cry Cries are high pitched and shrill
Nurse should talk with the mother about eating habits
Nurse should refer the infant for further testing
Nurse should Do nothing; these are expected findings for an infant this age
Nurse should tell the mother to bring baby back in 1 week to recheck.
13
What part of the brain coordinates autonomic nervous system activity and the stress response?
cerebellum
thalamus
Basal ganglia
hypothalamus
14
What does the frontal lobe control? (SATA)
Emotions
Hearing/Taste
Behavior
Personality
Intellectual function
Motor Speech
15
68 yo pt stands w/ feet together and arms at his side w eyes closed, he starts to sway and moves feet apart. Document
Lack of coordination
Ataxia
Negative Homans sign
Postive Romberg sign
16
Which of these statements about the peripheral nervous system is correct?
The CNs enter the brain through the spinal cord
Efferent fibers carry sensory input to CNS through spinal cord
It is inside the CNS and carry impulses through their motor fibers
It carries input to the CNS by afferent fibers and away by efferent fibers
17
32 yo noticed sudden jerky movements mainly in hands and arms that come and go, doesn't occur while sleeping. Suggests?
Myoclonus
Athetosis
Chorea
Tics
18
What are basic, involuntary, reflex mechanisms of the nervous system?
homeostasis
Reflexes
diencephalon
Cranial nerves
19
The nurse knows that testing kinesthesia is a test of a persons:
Fine touch
Perception of vibration
Position sense
Motor coordination
20
Pt has just had neurosurgery. To assess for ICP, what would the nurse include in assessment?
Mental status, deep tendon reflex, sensory function, and pupillary response
LOC, motor function, pupillary response, and vital signs.
Deep tendon reflexes, vital signs, and coordinated movements
CNs, motor function, and sensory function
21
CN assessment finds: asymmetry when pt smiles or frowns, uneven lifting of eyebrows, sagging of lower lids.
Indicate dysfunction of motor component of CN X
Indicate dysfunction of motor component of CN VII
Indicate dysfunction of motor component of CN IV
Indicate dysfunction of motor component CN XI
22
What lobe has the primary auditory receptor center?
Temporal lobe
Frontal lobe
Parietal lobe
Occipital lobe
23
Each hemisphere is divided into _______.
Five lobes
Four Systems
Two lobes
Four lobes
24
Pt w/ CVA, arm is immobile against body when walking, flexion of shoulder, elbow, wrist, and adduction of shoulder
Type of gait disturbance = Spastic hemiparesis
Type of gait disturbance = Scissor gait
Type of gait disturbance = Parkinsonian gait
Type of gait disturbance = Cerebellar ataxia
25
What nerves enter and exit the brain directly rather than through the spinal cord?
Spinal nerves
Motor fibers
Cranial nerves
glands
26
50 yo pt c/o weakness in left arm and leg for past week. The nurse should perform which type of neurologic exam?
Glasgow Coma Scale
Screening neurologic exam
Complete neurologic exam
Neurologic recheck exam
27
Testing deep tendon reflexes. When striking Achilles heel & quadricep muscle, unable to elicit a reflex. Next response?
Complete the examination, and test these reflexes again.
Document these reflexes as 0 on a scale of 0 to 4+
Ask the pt to lock fingers and pull.
Refer the pt to a specialist for further testing.
28
What mediates posture control, urination, and pain response?
brainstem
Spinal cord
Pituitary gland
diencephalon
29
When the nurse is testing the triceps reflex, what is the expected response?
Extension of the forarm
Extension of the hand
Pronation of the hand
Flexion of the hand
30
The nurse places a key in hand of pt and he identifies a penny. What term is used to describe?
Extinction
Tactile discrimination
Graphesthesia
Astereognosis
31
Recent HI responds to pain by extending, adducting, and internally rotating arms, palms pronate, LE extend plantar flexi
Pt response indicates a completely nonfunctional brainstem
Pt response is normal and will go away in 24-48 hours
Pt response Indicates a lesion of the cerebral cortex
Pt response is omnous sign and may indicate brain stem injury
32
If a patient is noticing changes in personality and ability to understand, what cerebral lobe is responsible for these?
Frontal
Temporal
Occipital
Parietal
33
What is the central core of the brain, consisting mostly of nerve fibers?
Brain Stem
thalamus
hypothalamus
Pituitary gland
34
To test for gross motor skill and coordination of a 6 yo, which of these techniques would be appropriate? Ask the child
To hop on one foot
To stand on his head
To make funny faces at the nurse
To touch his finger to his nose
35
68 yo who sustained head injury 3 days earlier tells nurse he is on cruise ship and is 30 yo. Finding indicative of?
Uncooperative behavior
Great sense of humor
Decreased LOC
Inability to understand questions
36
What part of the frontal lobe mediates motor speech?
Hypothalamus
Postcentral gyrus
Wernicke's area
Broca's area
37
Pt in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma?
24
6
15
12
38
A nurse receives an accidental needle prick. To interpret this sensation, which of these areas must be intact?
Lateral spinothalamic tract
Corticospinal tract, medulla, and basal ganglia
Pyramidal tract, hypothalamus, and sensory cortex
Anterior spinothalamic tract, basal ganglia, and sensory cortex
39
Testing fx of CN XI. Which statement best describes the response expected if nerve intact?
Sticks out the tongue midline without tremors or deviation.
Follows an opject with his/her eyes without nystagmus or strabismus.
Demonstrates the ability to hear normal conversations.
Moves the head and shoulders against resistance with equal strength.
40
What are the large bands of gray matter that help initiate and coordinate movements and central control automatic moveme
hypothalamus
thalamus
cerebellum
Basal ganglia
41
What part of the brain is considered the main relay station where pathways form synapses on the way to cerebral cortex?
cerebellum
hypothalamus
thalamus
Basal ganglia
42
62 yo has a stooping posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movement
Finding consistent with Cerebral palsy
Finding consistent with Parkinsonism
Finding consistent with Muscular Dystrophy
Finding consistent with Cerebellar ataxia
43
What lobe is the primary visual receptor center?
Occipital lobe
Occipital lobe
Parietal lobe
Frontal lobe
44
To assess head control of 4 mo old, the nurse lifts up the infant in prone position while supporting chest. Normal respo
Holds the head at 45 degrees, and keeps the back straight
Flexes the knees and elbows with the back straight
Extends the arms, and drops down the head
Raises the head, and arches the back
45
Superficial reflexes on adult. When stoking up lateral side of sole of foot and across ball, plantar flexion of the toes
Document plantar reflex 2+ on a scale of 0 to 4+
Document plantar reflex abnormal
Document plantar reflex present
Document positive Babinski sign
46
What part of the brain regulates sleep and appetite?
hypothalamus
cerebellum
thalamus
Basal ganglia
47
What part of the parietal lobe is the primary center for sensation?
Hypothalamus
Postcentral gyrus
Broca's Area
Wernicke's area
48
Health hx of 74 yo, he drinks alcohol daily and he has tremor in hands that affects ability to hold things. Response?
We'll do some tests to see what is causing the tremor
Does the tremor change when you drink alcohol?
You really shouldn't drink so much alcohol; it may be causing your tremor.
Does your family know you are drinking everyday?
49
The area of the nervous system that is responsible for mediating reflexes?
Spinal cord
Medulla
Cerebral cortex
Cerebellum
50
What part of the brain is involved with motor coordination, voluntary movements, equilibrium, and muscle tone?
hypothalamus
cerebellum
thalamus
Basal ganglia
51
Nurse knows that determining whether a person is oriented to his or her surroundings will test the function of what?
Cerebrum
CNs
Cerebellum
Medulla Oblongata
52
The Central Nervous System is made up of? (SATA)
Spleen
Spinal cord
Liver
Kidneys
Brain
Lymph Nodes
53
What are functions of reflexes? (SATA)
Maintain balance
Running
Swimming
Maintain muscle tone
54
The outer layer of nerve cell bodies, is the center for a human's highest functions. Governs thoughts, memory, reasoning
Cerebral Cortex
Cerebellum
Frontal Lobe
Thalamus
55
70 yo woman explains everytime she gets up in morning or after sitting she gets dizzy and feels like falling over. Best
have you been extremely tired lately
You need to get up slowly when you've been lying down or sitting
I'll refer you for a complete neurologic examination
You probably need to drink more fluids
56
Each half of the cerebrum is?
Hemisphere
System
Broca's Area
Lobe
57
Pt w/late stage brain tumor. Reflex hammer, nurse draws a light stroke and toes fan inward. Nurse interprets result as:
Clonus, which is a hyperactive response
Negative Babinski sign, which is normal for adults
Positive Babinski sign, which is abnormal for adults
Achilles reflex, which is an expected result
58
Neurological exam of 35 yo pt, nurse asks to relax muscles completely and moves each extremity through full ROM. Result?
Firm, rigid resistance to movement.
Mild, even resistance to movement.
Slight pain with some directions of movement.
Hypotonic muscles as a result of total relaxation.
59
What is the main highway for fiber tracts that connect the brain to the spinal nerves?
diencephalon
Pituitary gland
Spinal cord
brainstem
60
The mom of a 1 mo old asks why it takes so long for infants to roll over? The reason is?
Demyelinating process must be occurring in infant
Myelin is needed to conduct & the neurons of a newborn are not myelinated.
Cerebral cortex is not fully developed
Spinal cord is controlling movement d/t cerebellum not fully developed.
61
What part of the nervous system includes all nerve fibers outside the brain and spinal cord and carries messages?
Peripheral nervous system
diencephalon
Central nervous system
Primary auditory receptor
62
Motor pathways of the spinal cord and brainstem synapse in the thalamus?
True
False
63
Pt unable to perform rapid alternative movement such as rapidly patting knees. Nurse should document?
Presence of dysdiadochokinesia
Astereognosis
Loss of kinesthesia
Ataxia
64
Neurologic exam on 41 yo w DM. Tuning fork pt is unable to feel vibrations on great toe or ankle bilaterally.
Peripheral neuropathy
Hyperalgesia
Hyperesthesia
Lesion of sensory cortex
65
Pt w/ severe nystagmus in both eyes of patient. Which conslusion is correct? Severe nystagmus in both eyes:
Is a normal occurance
May indicate disease of the cerebellum or brainstem
Indicates a visual problem, and a referral to an ophthalmologist is indicat
Is a sign that the patient is nervous about the examination
66
A pt w/head injury is unconscious. What would nurse expect to find when testing pts deep tendon reflexes?
Because there are 31 pairs, no effect result if only one nerve severed
Adjacent spinal nerves will continue to carry sensations for the dermatome
Only affect motor fx of pt because spinal nerves have no sensory component.
The dermatome served by this nerve will no longer experience any sensation
67
29 yo pt c/o always dropping things and falling. Test rapid alt movements, unable to pat both knees. Slow & misses
Suspect Inability to understand directions
Suspect Lesion of CNIX
Suspect vestibular disease
Suspect dysfunction of the cerebellum
68
69 yo admitted to psych dept, wife thinks he's getting confused. Which finding would indicate Alzheimer's disease?(SATA)
Rapid mood swings, from calm to tears, for no apparent reason
Difficulty performing familiar tasks, such as placing a phone call
Sometimes having trouble finding the right word
Getting lost in ones own neighborhood
Misplacing items, such as putting dish soap in refrigerator
Occasionally forgetting names or appointments
69
The basal ganglia are responsible for controlling voluntary movements?
True
False
70
80 yo pt hands show tremors when he reaches for things and his head is always nodding. Which statement accurate?
These findings should be evaluated for a cerebellar lesion
These findings could be related to hyperthyroidism
These findings are normal, resulting from aging
These findings could be related to alcohol withdrawals.
71
80 yo pt has inability to identify vibrations at ankle and big toe, a slower gait, slightly impaired tactile sensation.
Interpret: CN dysfunction
Interpret: Demyelination of nerves attributable to a lesion
Interpret: Lesion in the Cerebral cortex
Interpret: Normal changes attributable to age
72
30 yo pt tells nurse she is unsteady and difficulty maintaining balance. Which area of the brain is related to this?
Brainstem
Extrapyramidal tract
Thalamus
Cerebellum
73
Pt fell and hit head, found wandering at 2am. Pt is clumsy, unable to follow instructions, and overshoots the mark.
Nurse suspects cerebrovascular accident
Nurse suspects peripheral neuropathy
Nurse suspects cerebral injury
Nurse suspects acute alcohol intoxication
74
The cerebellum is the center for speech and emotions?
True
False
75
During a health hx, a pt tells nurse it feels like the room is spinning around me. What to document?
Dizziness
Seizure activity
Vertigo
Syncope
76
Which of these tests would the nurse use to check the motor coordination of 11 mo old infant?
Denver II
Stereognosis
Deep tendon reflexes
Rapid alternating movements
77
78 yo pt wife c/o he occasionally has ST memory loss & confusion. When assessing sensory system, which action most appro
Proced with exam of each test, make certain wife understands
Perform tests, knowing that mental status does not affect sensory ability
Before testing assess the pts mental status and ability to follow direction
Not test sensory system as part of exam because results not valid
78
What is the major respiratory center with basic vital functions such as regulating temperature, HR, and BP?
cerebellum
hypothalamus
Basal ganglia
thalamus
79
The hypothalamus controls body temperature and regulates sleep?
False
True
80
This controls voluntary movement, reasoning, and sensation
Thalamus
Cerebral Cortex
Frontal Lobe
Cerebellum

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