27 Dec A 45-year-old man is in the

Question 1

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. The nurse interprets this result as:

a negative Babinski sign, which is normal for adults.

a positive Babinski’s sign, which is abnormal for adults.

clonus which is a hyperactive response.

the Achille’s reflex, which is an expected response.

Question 2

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?

scissors gait.

cerebellar ataxia.

parkinsonian gait.

spastic hemiparesis.

Question 3

The nurse places a key in the hand of the patient and he identifies it as a penny. What term would the nurse use to describe this finding?

extinction.

astereognosis.

stereognosis.

graphethesia.

uestion 4

The nurse is providing instructions to newly hired graduates about the Mini-Mental State Examination. Which statement best describes this examination?

Scores below 30 indicate cognitive impairment.

It is a good tool to evaluate mood and thought processes.

It is a good tool to detect delirium and dementia to differentiate these from psychiatric mental illness.

It is useful for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time.

Question 5

The nurse is doing an assessment on a 29-year-old woman who visits the clinic complaining of “always dropping things and falling down.” While testing rapid alternating movements, the nurse notices that the woman is unable to pat both her knees. Her response is very slow and she misses frequently. What should the nurse suspect?

vestibular disease.

lesion of cranial nerve IX.

dysfunction of the cerebellum.

inability to understand directions.

Question 6

Cranial nerve IV is known as:

Oculomotor

Trigeminal

Hypoglossal

Trochlear

Question 7

The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply.

Test for Murphy’s sign.

Test for Blumberg’s sign.

Test for shifting dullness.

Perform Iliopsoas muscle test.

Test for fluid wave.

Question 8

In order to document that bowel sounds are absent, the nurse must listen for [ ] minutes. ( Use the number and not the text word)

Answer

5

Question 9

A patient has had a cerebrovascular accident, or stroke. He is trying very hard to communicate. He seems driven to speak and says, “I buy obie get spirding and take my train.” What is the best description of this patient’s problem?

Global aphasia

Broca’s aphasia

Echolalia

Wernicke’s aphasia

Question 10

A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices and area of dullness above the right costal margin of about 10cm. The nurse should:

document the presence of hepatomegaly.

ask additional history questions regarding alcohol intake.

describe this as an enlarged liver and refer him to a specialist.

consider this a normal finding and proceed with the examination.