Chapter 14 Care of the Patient with a Neurologic Disorder

Chapter 14  Care of the Patient with a Neurologic Disorder

MULTIPLE CHOICE

1. The name of this area of the brain means “bridge.” It is the origin of cranial nerves V through VIII and is responsible for sending impulses to the structures inferior and superior to it. It also contains a respiratory center that complements the part of the brain stem located inferior to it. It is called the

1. medulla oblongata.
2. diencephalon.
3. cerebellum.
4. pons.

ANS: D
The pons connects the midbrain to the medulla oblongata. The word pons means “bridge.” It is the origin of cranial nerves V and VIII.

DIF: Cognitive Level: Knowledge REF: Page 654 OBJ: 3 TOP: Anatomy and physiology KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

2. The cranial nerve that supplies most of the organs in the thoracic and abdominal cavities and also carries motor fibers to glands that produce digestive juices and other secretions is the

1. somatic motor nerve.
2. visceral sensory nerve.
3. abducens nerve.
4. vagus nerve.

ANS: D
The vagus nerve extends from the throat, larynx, and organs in the thoracic and abdominal cavities. It is responsible for sensations and will accelerate peristalsis when stimulated.

DIF: Cognitive Level: Knowledge REF: Page 655, Table 14-1
OBJ: 5 TOP: Anatomy and physiology
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

3. A patient has a head injury and is presenting with signs and symptoms of increased intracranial pressure. Which nursing intervention would be helpful in reducing this pressure?

1. Place the neck in a neutral position to promote venous drainage.
2. Suction hourly to stimulate the cough reflex.
   Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Test Bank 14-2

c. Add extra blankets to keep the patient warm.
d. Turn the patient frequently to prevent skin impairment.

ANS: A
Place the neck in a neutral position (not flexed or extended) to promote venous drainage.

DIF: Cognitive Level: Application REF: Page 671 OBJ: 13
TOP: Intracranial pressure (ICP) KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

4. When obtaining a health history from a patient with a neurological problem, the nurse is likely to elicit the most valid response from the patient with which question?

1. “Do you have any sensations of pins and needles in your feet?”
2. “Does the pain radiate from your back into your legs?”
3. “Can you describe the sensations you are having in your head?”
4. “Do you ever have any nausea or dizziness?”

ANS: C
For patients with suspected neurological conditions, the presence of many symptoms or subjective data may be significant.

DIF: Cognitive Level: Application REF: Page 657 OBJ: 9 TOP: Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

5. A patient has been injured in a motorcycle accident and is presenting with signs and symptoms of increased intracranial pressure. What is the most significant sign or symptom of increased intracranial pressure?

1. Pupil changes
2. Ipsilateral paralysis
3. Vomiting
4. Decrease in the level of consciousness

ANS: D
Collection of objective data includes a change in level of consciousness. A change in the level of consciousness is the earliest sign of increased intracranial pressure.

DIF: Cognitive Level: Analysis REF: Pages 661, 669
OBJ: 12 TOP: Intracranial pressure (ICP)
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

6. The patient, injured in an automobile accident, is being evaluated in the emergency department for possible head injury. Which test should not be done if there is an indication of increased intracranial pressure?

1. CT scan
2. MRI scan
3. Lumbar puncture
4. Electroencephalogram

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Test Bank 14-3

ANS: C
A lumbar puncture is contraindicated in patients who might have increased intracranial pressure, because the withdrawal of fluid may cause the medulla oblongata to herniate downward into the foramen magnum.

DIF: Cognitive Level: Analysis REF: Pages 670, 704
OBJ: 13 TOP: Trauma KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity