Preview Extract
Chapter 28
1. A client experiencing extreme emotional stress is observed to be exhibiting both
tachycardia and tachypnea. The nurse recognizes that the return to normal limits of these
processes relies primarily of the function of which component of the client’s nervous system?
1. Parasympathetic
2. Central
3. Peripheral
4. Sympathetic
Answer: Parasympathetic
Rationale:
The parasympathetic nervous system is responsible for returning the body’s functions to
normal after they have been stimulated by the sympathetic system. The central nervous
system acts as a message center that translates signals from other parts of the body. These
signals are transported to the central nervous system by the peripheral nervous system.
2. A client who fell while skiing reports mild pain at the site of his coccyx. An X-ray shows
no bone damage, but the client is concerned that he has damaged his spinal cord. Which of
the following responses shows the nurse’s understanding of the client’s concern?
1. “Your spinal cord ends above your coccyx bone, so there is no need to worry.”
2. “I see no reason to be worried, but I can share your concern with your health care
provider.”
3. “As long as there is no break in the vertebral column, your spinal cord is undamaged.”
4. “If you are not experiencing any weakness or numbness now, your spinal cord is
undamaged.”
Answer: “Your spinal cord ends above your coccyx bone, so there is no need to worry.”
Rationale:
The spinal cord is shorter than the vertebral column, so damage to the spinal cord by such an
injury is unlikely. The spinal cord may be damaged even if the vertebral column is unbroken.
The symptoms described may manifest hours to days after an injury. The nurse should
attempt to address the client’s concerns rather than directing them to the health care provider.
3. An intensive care unit (ICU) nurse is preparing to assess a client who experienced multiple
trauma injuries and is on assisted ventilation for level of conscious (LOC). The nurse
recognizes that the FOUR Score Consciousness Scale is the most appropriate evaluation tool
because it:
1. Does not include verbal responses.
2. Requires minimal interaction on the part of the client.
3. Is designed especially for intensive care unit clients.
4. Focuses primarily on assessment of cognitive ability.
Answer: Does not include verbal responses.
Rationale:
Verbal response is not a component of the FOUR Score Consciousness Scale, making it fully
applicable for intubated clients. The tool does require client participation in evaluating its
four focus components: eye, motor, brainstem, and respiration. Cognitive ability is not
assessed by this tool, nor is it designed for any specific type of client.
4. An emergency department triage nurse receives a report that an incoming client has a
Glasgow Coma Scale (GCS) score of 8. The nurse alerts the staff that the client’s priority
intervention is:
1. Assessment of airway, breathing, and circulation.
2. Re-assessment using the FOUR Score Consciousness Scale.
3. Introduction of an intravenous access device.
4. Establishment of orientation to time, place, and person.
Answer: Assessment of airway, breathing, and circulation.
Rationale:
A GCS (Glascow Coma Scale) score of 8 or less is usually indicative of coma. A comatose
client receives high priority, and the nurse will utilize the ABCs of care in this case. None of
the remaining options has priority when determining care for the comatose client. Reassessment using the FOUR Score Consciousness Scale would not be a priority since the
client’s level of consciousness has already been assessed and established. Assessing the
vascular system would be addressed after airway, breathing, and circulation has been deemed
stable. Orientation to time, place, and person is not relevant to the care of a comatose client.
5. A 70-year-old client being admitted to a skilled nursing unit tells the interviewing nurse
that he cannot remember anyone ever suggesting that he receive the pneumococcal vaccine.
Which of the following interventions should the nurse implement?
1. During the admission interview, educate the client on the benefits of the vaccination in
preventing pneumococcal meningitis.
2. Tell the client that while the risk of developing pneumococcal meningitis is low, he should
consider the vaccination.
3. Inform the health care provider that the client needs to be informed regarding vaccination
against pneumococcal meningitis.
4. Offer to provide the client with written information regarding the risks and benefits of the
pneumococcal vaccine.
Answer: During the admission interview, educate the client on the benefits of the vaccination
in preventing pneumococcal meningitis.
Rationale:
For patients older than 65 years of age, the pneumococcal vaccine should be considered due
to the increased risk of pneumococcal meningitis among that population. With the increased
risk, the need for the vaccination should be stressed through direct client education, not by
written material only. The need to educate the client should not be deferred to the health care
provider.
6. A nurse is interviewing a client whose wife reports that, “he’s really forgetting things more
these days.” In order to provide the best assessment of this complaint, the nurse should:
1. Use the mnemonic OLD CARTS.
2. Ask the wife to give examples of the client’s forgetfulness.
3. Inquire of the client if he too feels he’s “forgetful.”
4. Have the client take the Mini-Mental Status Examination (MMSE).
Answer: Use the mnemonic OLD CARTS.
Rationale:
In order to obtain as full a description of the reported forgetfulness as possible, the nurse
should use the mnemonic OLD CARTS (Onset, Location, and Duration of symptoms,
Characteristics, Aggravating/associated factors, Relieving factors, Temporal factors, and
Severity of symptoms) to ensure all necessary information is obtained. Asking the wife to
provide examples or inquiring of the client if he agrees with his wife will not necessarily
ensure a thorough assessment of the client’s alleged forgetfulness.
7. The nurse recognizes that a client with a dysfunctional vagus nerve (CN X) is at risk for
impaired skin integrity related to:
1. Excessive salivation.
2. Bell’s palsy.
3. Ménière’s disease.
4. Tongue deviation.
Answer: Excessive salivation.
Rationale:
Vagus nerve (CN X) damage can result in excessive drooling. Bell’s palsy is a result of facial
nerve (CN VII) dysfunction that causes a drooping of facial muscles. Ménière’s disease is a
result of a problem with the acoustic nerve (CN VIII) that results in vertigo, tinnitus, or
disturbed balance. Hypoglossal nerve (CN XII) dysfunction can result in tongue deviation.
8. The nurse observes signs that a client may be experiencing dysfunction related to the
vestibular branch of his acoustic nerve (CN VIII). In order to minimize the client’s risk for
injury, the nurse should:
1. Identify the client as a “fall risk.”
2. Assess the client’s gag reflex prior to offering food or liquids.
3. Apply an “eye bubble” to the client at bedtime.
4. Assess the client’s vision using a Snellen chart.
Answer: Identifying the client as a “fall risk.”
Rationale:
Dysfunction of the vestibular branch of the acoustic nerve may result in vertigo or disturbed
balance, making the client at risk for falls. Precautions to minimize this risk should be
implemented. Dysfunction of the glossopharyngeal (CN IX) and vagus (CN X) nerves are
likely to result in a poor or absent gag reflex. During sleep, the use of an “eye bubble” is
appropriate when damage to the facial nerve (CN VII) results in the inability to keep the
eyelid closed. A Snellen chart is an eye chart used to measure visual acuity that may be
altered due to dysfunction of the optic nerve (CN II)
9. During an assessment of the cranial nerves, the nurse asks the client to “Stick out your
tongue.” When the client complies, the nurse observes that the tongue deviates markedly to
the right side. The nurse documents that the client is exhibiting:
1. An abnormal hypoglossal nerve response.
2. Findings consistent with first cranial nerve damage.
3. A sluggish oculomotor response.
4. Pronounced absence of the Homans’ sign.
Answer: An abnormal hypoglossal nerve response
Rationale:
Cranial nerve XII (hypoglossal) is tested by having the client stick the tongue out. An
abnormal finding is that the tongue deviates to either side. Cranial nerve I is the olfactory
nerve, and is assessed by having the client smell; cranial nerve III is the oculomotor nerve
and, along with the trochlear and abducens nerves, helps the eye move. Homans’ sign is a
check for thrombophlebitis in the calves of the legs.
10. The nurse best describes the function of the Mini-Mental Status Examination (MMSE) to
the wife of a client who has “been forgetting things lately” by stating:
1. “The test has a few questions that are used to thoroughly assess your husband’s mental
status.”
2. “It’s a test that will help us determine why he is getting forgetful.”
3. “The test has a few simple questions that will test him for dementia.”
4. “Being forgetful isn’t unusual, but this test will rule out any serious problems.”
Answer: “The test has a few questions that are used to thoroughly assess your husband’s
mental status.”
Rationale:
The Mini-Mental Status Examination (MMSE) is a tool that systematically assesses a client’s
orientation, language, memory, writing skills, ability to follow commands, ability to make
calculations, and degree of constructional abilities. The MMSE evaluates more than just
forgetfulness. The examination is not designed to identify causes of cognitive dysfunction. It
is insensitive to suggest the client is experiencing dementia at this point in the assessment
process.
11. The nurse is caring for a client who, though depressed, has been oriented to time, place,
and person. For the last 24 hours, however, the client has repeatedly asked the staff, “Where
am I?” The nurse anticipates that the most appropriate tool to assess this client’s cognitive
status is the:
1. Cognitive Capacity Screening Examination (CCSE).
2. Mini-Mental Status Examination (MMSE).
3. Beck Depression Inventory (BDI).
4. Duke Anxiety-Depression Scale (DUKE-AD).
Answer: Cognitive Capacity Screening Examination (CCSE).
Rationale:
The Cognitive Capacity Screening Examination (CCSE) is most reliable for distinguishing
between acute and chronic cognitive disorders. While an excellent screening tool, the MiniMental Status Examination (MMSE) is not the tool of choice for this client due to the acute
nature of the onset of symptomology. The Beck Depression Inventory (BDI) and the Duke
Anxiety-Depression Scale (DUKE-AD) evaluate depression, but have no focus on cognitive
dysfunction.
12. After providing a client’s son with an explanation of the function of the Mini-Mental
Status Examination (MMSE), the nurse is confident of the son’s understanding when he
states:
1. “So this test will evaluate my dad’s ability to think, reason, and make reasonably good
decisions.”
2. “These questions will give us a good idea if Dad is mentally healthy enough to continue to
live alone.”
3. “If Dad passes this test, we will know that his mind is still okay.”
4. “I’m sure Dad will do well on the test; he’s always been smart.”
Answer: “So this test will evaluate my dad’s ability to think, reason, and make reasonably
good decisions.”
Rationale:
The MMSE assesses the higher cortical functions of thinking and reasoning as well as level
of consciousness, orientation, attention, memory, affect and insight, speech and language,
fund of knowledge, and abstraction. There are other factors besides those evaluated by the
MMSE that can impact one’s ability to live independently. That evaluation is not a pass/fail
type of testing and does not provide definite proof of mental wellness. One’s intelligence is
not the focus of the evaluation.
13. While assessing an unconscious client’s neurological status, the nurse applies pain by
pinching the sternocleidomastoid muscle. This technique is implemented because:
1. Pain will make abnormal motor responses observable.
2. An unconscious client’s pain threshold is abnormally high.
3. Response to pain is an indicator of cognitive function.
4. The client is most likely to respond to pain at that site.
Answer: Pain will make abnormal motor responses observable.
Rationale:
In the unconscious patient, a painful stimulus such as the sternocleidomastoid pinch may
elicit an observable abnormal motor response. The pain threshold of an unconscious client is
not necessarily high. Cognitive function is not tested by introduction of painful stimuli. It is
the presence of pain, not its location, that is likely to elicit a response.
14. The nurse recognizes that which of the following assessment observations of a comatose
client has the greatest implication?
1. Both arms are extended and adducted and with the palms facing down.
2. Arms, wrist, and fingers are flexed and adducted.
3. Muscles of the entire upper extremities are flaccid bilaterally.
4. Fasciculational twitching occurs in the small muscle groups of both arms.
Answer: Both arms are extended and adducted and with the palms facing down.
Rationale:
Both arms are extended and adducted and with the palms facing down describes decerebrate
posturing, believed to be the most grave of the responses provided as options. Arms, wrist,
and fingers are flexed and adducted describes decorticate posturing. Muscles of the entire
upper extremities are flaccid bilaterally describes paralysis, while fasciculational twitching is
involuntary, arising from the spontaneous discharge of a bundle of skeletal muscle fibers, and
is usually benign.
15. The nurse is assessing the muscle stretch reflexes on a client who has repeatedly
demonstrated 3+ responses. The nurse recognizes the implication of this data to mean that:
1. While brisk, it may be normal for this client.
2. This is a below-normal response.
3. There is indication of central nervous system dysfunction.
4. This is generally considered a normal response.
Answer: While brisk, it may be normal for this client.
Rationale:
A 3+ response or grade is considered brisk but may be normal for some individuals; normal
response is generally graded as a 2+; 1+ is a diminished response while a 4+ is indicative of
CNS dysfunction.
16. The nurse recognizes which of the following observations as a positive Babinski sign?
1. Dorsiflexion of the great toe, with fanning of the other toes
2. Curling of all the toes in response to stroking stimulation
3. Feeling a buzzing sensation in the foot when touched with a tuning fork
4. Inability to identify two simultaneous points of pain on the foot
Answer: Dorsiflexion of the great toe, with fanning of the other toes
Rationale:
Dorsiflexion of the great toe, with fanning of the other toes, shows pathologic reflexes
(positive Bakinski sign). Vibratory sense is tested using a tuning fork on one of a variety of
bony prominences. Diminished buzzing sensation is pathological. Two-point discrimination is
tested by touching the client with one or both sharp objects at the same time; the inability to
identify if there were multiple pain sites reflects pathology.
17. When the nurse assesses the client’s abdominal superficial reflexes, the umbilicus moves
in the direction of the skin stimulated. The nurse documents this observation as:
1. A positive (+) response.
2. A negative (-) response.
3. An absence of response.
4. A questionable response.
Answer: A positive (+) response.
Rationale:
When evaluating superficial reflexes, they are scored as being either present (+) or absent (-).
Observing the umbilicus moving in the direction of the skin being stimulated is a (+)
response.
18. The nurse is expected to assess a client for the presence of pathological reflexes. Which
of the following reflexes should the nurse plan to assess?
Select all that apply.
1. Babinski
2. Grasp
3. Snout
4. Sucking
5. Achilles
Answer: 1. Babinski
2. Grasp
3. Snout
4. Sucking
Rationale:
Babinski. The Babinski reflex is an example of a pathological reflex. Grasp. The grasp reflex
is an example of a pathological reflex. Snout. The snout reflex is an example of a
pathological reflex. Sucking. The sucking reflex is an example of a pathological reflex.
Achilles. The Achilles reflex is a muscle stretch reflex.
19. The nurse is about to educate a client on the side effects of a newly prescribed
medication. The client is both hearing and vision impaired. The nurse’s initial intervention is
to:
1. Be sure that the client has glasses on and functioning hearing aids during the discussion.
2. Provide a written explanation to supplement the nurse−client discussion.
3. Ask that a client’s family member be present during the educational session.
4. Arrange for the client’s room to be well lighted and quiet during the teaching session.
Answer: Be sure that the client has glasses on and functioning hearing aids during the
discussion.
Rationale:
In order for the client to be best prepared to respond to the instructions, the sensory
deficiencies must be first addressed; being sure the assistive devices are working and
properly in place is the initial intervention. While providing written material, having a family
member present, and assuring that the room is well lighted and quiet are all appropriate
interventions, they will not be as effective if the client’s hearing and visual deficiencies are
not first addressed.
20. The nurse is preparing to administer a Mini-Mental Status Examination (MMSE) on a 75year-old client admitted for clinical depression. The nurse’s initial intervention for this
specific client is to:
1. Plan for the test when the client will not to be rushed to complete it.
2. Repeat the instructions just prior to beginning the assessment.
3. Arrange for the client to be uninterrupted during the test.
4. Make sure the client is not hungry or in pain when taking the test.
Answer: Plan for the test when the client will not to be rushed to complete it.
Rationale:
Planning for the test when the client will not to be rushed to complete it is particularly
important for the elderly client due to decreased processing speed; allow adequate time for
the older client to respond to the examination items. Repeating the instructions, arranging for
the client to be uninterrupted, and addressing hunger and pain issues are interventions that are
appropriate for any client regardless of age.
21. An elderly client diagnosed with Type 2 diabetes mellitus frequently reports that his tea is
“way too sweet” even though the staff adds only the 1 teaspoon of sugar substitute the client
requests. The most likely reason for this response is that:
1. The client’s perception of sweetness has become more sensitive.
2. Sugar substitutes are sweeter than natural sugar.
3. Diabetes mellitus can alter one’s tolerance for sugar.
4. The client has not adjusted to the use of sugar substitutes.
Answer: The client’s perception of sweetness has become more sensitive.
Rationale:
The aging process generally increases one perception of salty, sweet, sour, and bitter tastes.
Diabetes mellitus does not have any known affects on one’s taste tolerance for sugar, but
rather on the body’s ability to utilize glucose. Sugar substitutes are not necessarily sweeter
than natural sugar, and adjustment to the substitute is more likely related to its general taste,
not to the degree of sweetness.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
