Health Assessment for Nursing Practice 6th Edition Wilson Test Bank
Chapter 15: Neurologic System
Wilson: Health Assessment for Nursing Practice, 6th Edition
MULTIPLE CHOICE
1. A nurse assesses a patient with a head injury who has slowing intellectual functioning,
personality changes, and emotional lability. The nurse correlates these findings with which
area of the brain?
a. Frontal lobe
b. Parietal lobe
c. Thalamus
d. Temporal lobe
ANS: A
The frontal lobe controls intellectual function, awareness of self, personality, and autonomic
responses related to emotion. The parietal lobe receives sensory input such as position sense,
touch, shape, and texture of objects. The thalamus is a relay and integration station from the
spinal cord to the cerebral cortex and other parts of the brain. The temporal lobe contains the
primary auditory cortex. It also interprets auditory, visual, and somatic sensory inputs that are
stored in thought and memory.
DIF: Cognitive Level: Understand
REF: p. 308
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
NURStoIthe
M the nurse correlates which clinical
2. In assessing a patient with damage
NGoccipital
TB.COlobe,
manifestation to this injury?
a. Intentional tremors
b. Visual changes
c. Decreased hearing
d. Inability to formulate words
ANS: B
The occipital lobe contains the visual cortex. Intentional tremors are caused by cerebellar
problems. The temporal lobe contains the auditory cortex. The ability to formulate words
comes from the Broca area in the frontal lobe.
DIF: Cognitive Level: Understand
REF: p. 308
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
3. Which patient behavior indicates to the nurse that the patient’s facial cranial nerve (CN VII) is
intact?
a. The patient’s eyes move to the left, right, up, down, and obliquely.
b. The patient moistens the lips with the tongue.
c. The sides of the mouth are symmetric when the patient smiles.
d. The patient’s eyelids blink periodically.
ANS: C
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Health Assessment for Nursing Practice 6th Edition Wilson Test Bank
The finding in option C represents facial symmetry, which is controlled by the facial cranial
nerve (CN VII). The finding in option A represents movement of the extraocular muscles,
which are controlled by the oculomotor, trochlear, and abducens cranial nerves (CN III, IV,
and VI, respectively). The finding in option B represents movement of the tongue, which is
controlled by the hypoglossal cranial nerve (CN XII). The finding in option D represents
function of the oculomotor cranial nerve (CN III).
DIF: Cognitive Level: Apply
REF: p. 321
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
4. A nurse assessing a patient who had a cerebrovascular accident involving the Broca area
suspects expressive or nonfluent aphasia. What communication abilities does the nurse
anticipate from this patient?
a. The patient understands speech but is unable to translate ideas into meaningful
speech.
b. The patient is unable to comprehend speech and thus does not respond verbally.
c. The patient is able to understand speech but has difficulty forming words, creating
muffled speech.
d. The patient is unable to comprehend speech and responds inappropriately to
conversation.
ANS: A
The inability to translate ideas into meaningful speech or writing is termed expressive aphasia
or nonfluent aphasia and is associated with lesions in the Broca area in the frontal lobe. The
inability to comprehend the speech of others is called receptive aphasia or fluent aphasia and
NUWernicke
RSINGTarea
B.C
M temporal lobe. Speech pattern A is more
is associated with lesions in the
in O
the
consistent with patients who have involvement of muscles of speech rather than neurologic
deficits. Speech pattern D is not relevant to this patient.
DIF: Cognitive Level: Apply
REF: p. 317
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
5. The nurse hears in a report that a patient has receptive or fluent aphasia. What communication
abilities does the nurse anticipate from this patient?
a. The patient understands speech but is unable to translate ideas into meaningful
speech.
b. The patient is able to understand speech but has difficulty forming words creating
muffled speech.
c. The patient is unable to comprehend speech and thus does not respond verbally.
d. The patient is emotionally liable and cries easily, which interferes with the ability
to communicate.
ANS: C
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Health Assessment for Nursing Practice 6th Edition Wilson Test Bank
Option C is called receptive aphasia or fluent aphasia and is associated with lesions in the
Wernicke area in the temporal lobe. The inability to translate ideas into meaningful speech or
writing is termed expressive aphasia or nonfluent aphasia and is associated with lesions in the
Broca area in the frontal lobe. Speech pattern B is more consistent with patients who have
involvement of muscles of speech rather than neurologic deficits. Speech pattern D is not
relevant to this patient.
DIF: Cognitive Level: Apply
REF: p. 317
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
6. What is the earliest and most sensitive indication of altered cerebral function?
a. Unequal pupils
b. Loss of deep tendon reflexes
c. Paralysis on one side of the body
d. Change in level of consciousness
ANS: D
Maintaining consciousness represents the functions of and communication between the frontal
lobe and reticular activating system. Pupillary function represents function of the oculomotor
cranial nerve and the midbrain. Deep tendon reflexes represent function of the spinal cord and
reflex arcs. Movement represents function of the spinal cord and posterior frontal lobe.
DIF: Cognitive Level: Remember
REF: p. 318
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
NURSINGTB.COM
7. A patient reports having difficulty swallowing. Based on this information, how does the nurse
assess the cranial nerve related to swallowing?
a. Ask the patient about feeling the blunt end of a paper clip along the jaw line.
b. Observe the rising of the soft palate when the patient says “Ahh.”
c. Observe the symmetry of the face when the patient talks.
d. Assess taste on the anterior part of the tongue.
ANS: B
Option B tests the glossopharyngeal cranial nerve (CN IX), which is involved in swallowing.
The nurse must correlate difficulty swallowing with the cranial nerves involved with that
function and how to test it. The cranial nerves involved are IX, X, and XII. Option A tests the
sensory function of the trigeminal cranial nerve (CN V). Option C tests the motor function of
the facial cranial nerve (CN VII). Option D tests the sensory portion of the facial cranial nerve
(CN VII).
DIF: Cognitive Level: Analyze
REF: p. 319 | p. 322
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
8. A patient reports having difficulty swallowing. Based on this information, how does the nurse
assess the appropriate cranial nerve?
a. Ask the patient to stick out the tongue and move it in all directions.
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Health Assessment for Nursing Practice 6th Edition Wilson Test Bank
b. Ask the patient to move the head to the right and left.
c. Observe the symmetry of the face when the patient talks.
d. Assess for taste on the anterior part of the tongue.
ANS: A
Option A tests the hypoglossal cranial nerve (CN XII) that is involved in swallowing. The
nurse must correlate difficulty swallowing with the cranial nerves involved with that function
and how to test them. The cranial nerves involved are IX, X, and XII. Option B tests the
function of the spinal accessory cranial nerve (CN XI). Option C tests the motor function of
the facial cranial nerve (CN VII). Option D tests the sensory portion of the facial cranial nerve
(CN VII).
DIF: Cognitive Level: Analyze
REF: p. 323
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
9. In assessing a patient’s deep tendon reflexes, a nurse finds a patient has a 4+ triceps response.
How does the nurse interpret this finding?
a. A hyperactive response
b. A diminished response
c. An absent response
d. An expected response
ANS: A
Deep tendon reflexes are graded from 0 to 4+ and 4+ is a hyperactive response. A diminished
response is 1+. An absent response is 0. An expected response is 2+.
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T p. O328
DIF: Cognitive Level: Understand
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
10. The nurse holds the patient’s relaxed arm with elbow flexed at a 90-degree angle, places a
thumb over a tendon in the antecubital fossa, and strikes the thumb with the pointed end of the
reflex hammer. Which deep tendon reflex is the nurse assessing?
a. Brachioradialis
b. Biceps
c. Triceps
d. Deltoid
ANS: B
Option B is the correct technique for assessing the biceps deep tendon reflex. The technique
described in option A is not the correct one for assessing the brachioradial deep tendon reflex.
The technique described in option C is not the correct one for assessing the triceps deep
tendon reflex. There is no reflex to test the deltoid muscle.
DIF: Cognitive Level: Understand
REF: p. 328
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
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Health Assessment for Nursing Practice 6th Edition Wilson Test Bank
11. A patient has a compression fracture of the cervical spine at C7 to C8 that is impairing deep
tendon reflexes. Which response will the nurse expect from the affected deep tendon reflex?
a. Diminished to absent pronation of the arm
b. Diminished to absent flexion of the elbow
c. Diminished to absent extension of the elbow
d. Diminished to absent adduction of the upper arm
ANS: C
Diminished to absent extension of the elbow is an abnormal response from the triceps deep
tendon reflex that is innervated from C6, C7, and C8. Diminished to absent pronation of the
arm is an abnormal response from the brachioradial deep tendon reflex that is innervated from
C5 to C6. Diminished to absent flexion of the elbow is an abnormal response from the biceps
deep tendon reflex that is innervated from C5 to C6. Diminished to absent adduction of the
upper arm is not a response of any deep tendon reflex.
DIF: Cognitive Level: Analyze
REF: p. 328
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
12. A nurse holds the patient’s relaxed left arm, with elbow flexed at a 90-degree angle, in one
hand. The nurse palpates and then strikes the appropriate tendon just above the elbow with
either end of the reflex hammer. What is the expected response for this deep tendon reflex?
a. Flexion of the left elbow
b. Pronation of the left forearm
c. Supination of the left arm
d. Extension of the left elbow
ANS: D
NURSINGTB.COM
Extension of the left elbow is the normal response of the triceps deep tendon reflex. Flexion of
the left elbow would be a normal response for the biceps deep tendon reflex. Pronation of the
left forearm would be a normal response for the brachioradialis deep tendon reflex. Supination
of the left arm is not a response of any deep tendon reflex.
DIF: Cognitive Level: Analyze
REF: p. 328
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
13. A nurse holds the patient’s relaxed arm with the elbow flexed at a 90-degree angle, places a
thumb over the appropriate tendon in the antecubital fossa, and strikes the thumb with the
pointed end of the reflex hammer. What is the expected response for this deep tendon reflex?
a. Extension of the left elbow
b. Pronation of the left forearm
c. Supination of the left arm
d. Flexion of the left elbow
ANS: D
Flexion of the left elbow is a normal response for the biceps deep tendon reflex. Pronation of
the left forearm is a normal response for the brachioradialis deep tendon reflex. Supination of
the left arm is not a response of any deep tendon reflex. Extension of the left elbow is the
normal response of the triceps deep tendon reflex.
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Health Assessment for Nursing Practice 6th Edition Wilson Test Bank
DIF: Cognitive Level: Analyze
REF: p. 328
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
14. How does a nurse test the brachioradial deep tendon reflex?
a. Uses the end of the handle on the reflex hammer to stroke the lateral aspect of the
sole of the patient’s foot from heel to ball.
b. Asks the patient to slightly pronate the relaxed forearm into the nurse’s hand and
strikes the appropriate tendon with the reflex hammer.
c. Holds the patient’s relaxed arm with the elbow flexed at a 90-degree angle in one
hand, and palpates and strikes the appropriate tendon just above the elbow with the
flat end of the reflex hammer.
d. Holds the patient’s relaxed arm with the elbow flexed at a 90-degree angle, places
a thumb over the appropriate tendon in the antecubital fossa, and strikes the thumb
with the pointed end of the reflex hammer.
ANS: B
Option B is the technique to assess the brachioradial deep tendon reflex. Option A is the
technique to test plantar flexion, the Babinski reflex. Option C is the technique to test the
triceps deep tendon reflex. Option D is the technique to test the biceps deep tendon reflex.
DIF: Cognitive Level: Understand
REF: p. 328
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
NURSINGTB.COM
15. A nurse dorsiflexes a patient’s right ankle 90 degrees and then uses a reflex hammer to strike
the appropriate tendon. What is the expected response for this deep tendon reflex?
a. Extension of the right lower leg
b. Plantar flexion of the right toes
c. Dorsiflexion of the right foot
d. Plantar flexion of the right foot
ANS: D
Plantar flexion is the expected response of the Achilles deep tendon reflex. Extension of the
right lower leg is the expected response for the patellar deep tendon reflex. Plantar flexion of
the right toes is the expected response for the plantar reflex (Babinski). Dorsiflexion of the
right foot is an incorrect response because the nurse is holding the patient’s foot in
dorsiflexion, therefore dorsiflexion would not be an expected response.
DIF: Cognitive Level: Understand
REF: p. 329
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
16. The nurse moves a wisp of cotton lightly across the anterior scalp, paranasal sinuses, and
lower jaw to test the function of which cranial nerve?
a. CN IV (trochlear nerve)
b. CN V (trigeminal nerve)
c. CN VI (abducens nerve)
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Health Assessment for Nursing Practice 6th Edition Wilson Test Bank
d. CN VII (facial nerve)
ANS: B
The CN V (trigeminal cranial nerve) supplies sensation to the cornea, iris, lacrimal glands,
conjunctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, and facial
skin. The CN IV (trochlear nerve) supplies downward and inward eye movement. The CN VI
(abducens nerve) supplies lateral eye movement. The CN VII (facial nerve) supplies
movement of facial expression muscles except the jaw, closes the eyes, and allows labial
speech sounds (b, m, w, and rounded vowels).
DIF: Cognitive Level: Understand
REF: p. 320
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
17. A nurse who is assessing a patient’s eyes finds that the pupils are equal, round, and react to
light and accommodation (PERRLA). These findings verify the expected functioning of
which cranial nerve?
a. Optic cranial nerve (CN II)
b. Oculomotor cranial nerve (CN III)
c. Trochlear cranial nerve (CN IV)
d. Abducens cranial nerve (CN VI)
ANS: B
The oculomotor cranial nerve (CN III) provides these eye functions. The optic cranial nerve
(CN II) provides vision. The trochlear cranial nerve (CN IV) provides eye movement
downward and inward. The abducens cranial nerve (CN VI) provides lateral eye movement.
N R I G B.C M
U S N REF:
T p. O319 | p. 320
DIF: Cognitive Level: Understand
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
18. In assessing a patient with a tumor in the pons, the nurse expects to find which abnormalities
due to pressure on cranial nerves?
a. Dilated pupils and ptosis
b. Facial asymmetry and impaired hearing
c. Difficulty swallowing
d. Impaired gag reflex
ANS: B
These abnormalities represent pressure on the facial and acoustic cranial nerves. The nurse
correlates the cranial nerves that exit from the pons which are trigeminal (CN V), abducens
(CN VI), facial (CN VII), and acoustic (CN VIII). These abnormalities represent pressure on
the oculomotor (CN III) that exits from the midbrain. This abnormality represents pressure on
the three cranial nerves that affect swallowing: glossopharyngeal (CN IX), vague (CN X), and
hypoglossal (CN XII). These cranial nerves exit the brain stem in the medulla oblongata. This
reflex is controlled by the vagus cranial nerve (CN IX), which exits the brain stem in the
medulla oblongata.
DIF: Cognitive Level: Analyze
TOP: Nursing Process: Assessment
REF: p. 312
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MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
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19. The nurse assesses the glossopharyngeal nerve (CN IX) by testing which reflex?
a. Corneal reflex
b. Gag reflex
c. Blink reflex
d. Cough reflex
ANS: B
Movement of the posterior pharynx and gag reflex test is controlled by the glossopharyngeal
cranial nerve (CN IX). The corneal reflex is controlled by the trigeminal cranial nerve (CN
V). The blink reflex is another name for the corneal reflex. The cough reflex is controlled
from the medulla oblongata.
DIF: Cognitive Level: Understand
REF: p. 312 | p. 322
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
20. Which cranial nerve is assessed when a nurse asks a patient to stick out the tongue and move
it side to side?
a. Vagus nerve (CN X)
b. Facial nerve (CN VII)
c. Abducens nerve (CN VI)
d. Hypoglossal nerve (CN XII)
ANS: D
N R I G B.C M
S Ntongue
T movement
O
The hypoglossal cranial nerve U
provides
for speech sound articulation (l, t,
n) and swallowing. The vagus cranial nerve provides movement for voluntary muscles of
phonation (guttural speech sounds) and swallowing. The facial cranial nerve provides
movement for facial expression muscles except the jaw, closes the eyes, and allows labial
speech sounds (b, m, w, and rounded vowels). The abducens cranial nerve provides for lateral
eye movement.
DIF: Cognitive Level: Understand
REF: p. 323
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
21. As a patient is walking down the hall, the nurse notices the patient’s staggering, unsteady gait.
What findings does the nurse anticipate on the neurologic examination?
a. When the patient stands with feet together, eyes open and then closed, an upright
posture is maintained.
b. When the patient touches the end of each finger to the thumb of the same hand, a
tremor is observed in the fingers.
c. When the patient is giving a history to the nurse, a tremor is noticed as the
patient’s hands rest in the lap.
d. When lying supine, the patient is able to move the heel of one foot down the shin
of the other leg.
ANS: B
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Health Assessment for Nursing Practice 6th Edition Wilson Test Bank
Patient B has a cerebellar problem as evidenced by the staggering gait (noted at the beginning
of the encounter) and the intention tremor on movement (noted during the examination).
Option A is a result of a negative Romberg test. This patient has a cerebellar problem, which
would result in a positive Romberg test. Option C describes a tremor at rest that occurs in
patients with parkinsonism rather than with cerebellar problems. Option D describes a normal
response on an examination of cerebellar function.
DIF: Cognitive Level: Apply
REF: pp. 323-325
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
22. A nurse asks the patient to stand with feet together, arms resting at the sides, with eyes open
and then with the eyes closed. Which response by the patient indicates an expected cerebellar
function?
a. Sways slightly and maintains upright posture with feet together
b. Is unable to stand upright after turning around in a circle once
c. Steps sideways when standing with feet together and eyes closed
d. Has to move arms horizontally to maintain balance
ANS: A
Maintaining balance indicates function of the cerebellum in the Romberg test. Losing balance
is an abnormal response, but turning in a circle is not a part of the Romberg test. Options C
and D are abnormal responses for the Romberg test (a positive Romberg test).
DIF: Cognitive Level: Apply
REF: p. 323
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: N
Physiologic
Integrity:
Adaptation: Alteration in Body
URSING
TB.CPhysiologic
OM
Systems
23. The nurse asks the patient to stand with feet together, arms resting at the sides, with eyes open
and then with the eyes closed. Which response by the patient indicates a problem in the
cerebellum?
a. Maintains balance when eyes are open, but loses balance with eyes closed
b. Is unable to stand upright after turning around in a circle once
c. Steps sideways when standing with feet together and eyes closed
d. Sways slightly and maintains upright posture with feet together
ANS: C
Option C is an abnormal response documented as a “positive Romberg” and indicates
cerebellar dysfunction. Option A is an abnormal response, but is indicative of a proprioceptive
problem rather than a cerebellar problem. Losing balance is an abnormal response, but turning
in a circle is not a part of the Romberg test. Option D is an expected response documented as
a “negative Romberg,” indicating appropriate cerebellar function for balance.
DIF: Cognitive Level: Apply
REF: p. 323
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
24. What is the patient’s expected response when the nurse is assessing graphesthesia?
a. Lies supine and runs one heel along the opposite shin
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Health Assessment for Nursing Practice 6th Edition Wilson Test Bank
b. Identifies a familiar object placed in the hands
c. Describes where a sensation of a vibrating tuning fork is felt
d. Identifies a letter or number drawn in the hand
ANS: D
Option D is a test of graphesthesia that assesses the parietal lobe and sensory tracts. Option A
tests cerebellar function of the lower extremities. Option B is a test of stereognosis that tests
the function of the parietal lobe and sensory tracts. Option C is a test of vibratory sense that
tests sensory tracts.
DIF: Cognitive Level: Understand
REF: p. 327
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
25. What is the patient’s expected response when the nurse is assessing stereognosis?
a. Identifies an object placed in the hand
b. Distinguishes numbers or letters traced in the palm of the hand
c. Touches the index finger of the nondominant hand to the nose
d. Walks heel to toe in a straight line
ANS: A
A nurse tests stereognosis by asking the patient to close his or her eyes and placing a small,
familiar object in the patient’s hand, asking him or her to identify it. Stereognosis tests
sensory nerve tracts and parietal lobe function. Activity B tests graphesthesia, a test of sensory
nerve tracts and parietal lobe function. Activity C tests cerebellar function of the upper
extremities. Activity D tests cerebellar function of the lower extremities.
N R I G B.C M
U S N REF:
T p. O327
DIF: Cognitive Level: Understand
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
26. A nurse correlates a patient’s altered stereognosis with a neurologic dysfunction in which part
of the nervous system?
a. Midbrain or pons
b. Temporal lobe or ascending nerve tracts
c. Frontal lobe or motor nerve tracts
d. Parietal lobe or sensory nerve tracts
ANS: D
A parietal lobe or sensory nerve tract dysfunction prevents a patient from identifying a
familiar object by touch, which is a definition of stereognosis. Sensory and motor tracts travel
though the midbrain and pons, but they are not tested with stereognosis. Ascending tracts
carry sensory data, but the temporal lobe provides functions of hearing rather than perception
of touch. Motor tracts carry impulses for movement and they exit from the frontal lobe, which
also helps to maintain consciousness.
DIF: Cognitive Level: Apply
REF: p. 327
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
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Health Assessment for Nursing Practice 6th Edition Wilson Test Bank
27. Which part of the nervous system is a nurse assessing when he places a vibrating tuning fork
on a patient’s wrist or ankle?
a. Frontal lobe and motor tracts
b. Parietal lobe and sensory tracts
c. Hypothalamus and sensory tracts
d. Cerebellum and motor tracts
ANS: B
The parietal lobe receives sensory input, such as vibratory sense and pain, through sensory
(afferent) tracts. The frontal lobe sends impulses governing movement through motor
(efferent) tracts. The hypothalamus functions include regulation of body temperature, hunger,
and thirst and formation of autonomic nervous system responses. The cerebellum provides
equilibrium and coordination of movement.
DIF: Cognitive Level: Understand
REF: p. 311 | p. 326
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific
Assessments
28. A patient has a herniated disk compressing the lumbar spine at L2, L3, and L4 that is
impairing deep tendon reflexes. Which response does a nurse expect from this patient?
a. Diminished contraction of the gastrocnemius muscle with plantar flexion of the
foot
b. Diminished contraction of the quadriceps muscle with extension of the lower leg
c. Diminished plantar flexion of the toes
d. Diminished dorsiflexion of the foot and flexion of the toes
ANS: B
NURSINGTB.COM
Option B is an abnormal response from the patellar deep tendon reflex that is innervated from
L2, L3, and L4. Option A is an abnormal response from the Achilles tendon reflex that is
innervated from S1 and S2. Option C is an abnormal response from the plantar reflex or a
positive Babinski sign. Option D is an abnormal response of ankle clonus.
DIF: Cognitive Level: Analyze
REF: p. 314 | p. 328
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
29. What technique does the nurse use to test the patellar deep tendon reflex?
a. Using the end of the handle on the reflex hammer, the nurse strokes the lateral
aspect of the sole of the patient’s foot from heel to ball.
b. Ask the patient to flex one knee to 90 degrees, while the nurse dorsiflexes the
ankle and strikes the appropriate tendon on the foot with the flat end of the reflex
hammer.
c. Ask the patient to flex one knee to 45 degrees, while the nurse plantar flexes the
ankle and strikes the appropriate tendon of the ankle with the pointed end of the
reflex hammer.
d. Ask the patient to flex one knee to 90 degrees, while the nurse strikes the
appropriate tendon in the knee with the blunt end of the reflex hammer.
ANS: D
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Health Assessment for Nursing Practice 6th Edition Wilson Test Bank
Option D is the technique for testing the patella deep tendon reflex. Option A is the technique
for testing plantar flex or the Babinski reflex. Option B is the technique for testing the
Achilles deep tendon reflex. Option C is not a correct technique for testing any reflex.
DIF: Cognitive Level: Understand
REF: p. 328 | p. 329
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
30. What technique does the nurse use to test ankle clonus?
a. Strokes the lateral aspect of the sole of the patient’s foot from heel to ball with a
reflex hammer
b. Supports the patient’s knee in flexed position and sharply dorsiflexes the foot and
maintains the flexion
c. Plantar flexes the ankle and strikes the appropriate tendon of the ankle with the
hammer.
d. Everts the ankle and slowly moves the ankle into plantar flexion and quickly
release the foot
ANS: B
Option B is the correct technique for assessing ankle clonus. Option A is the technique for
testing plantar flex or the Babinski reflex. Option C is not a correct technique for testing any
reflex. Option D is not a correct technique for testing any reflex.
DIF: Cognitive Level: Understand
REF: p. 329
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical
Assessment
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31. Which response does a nurse expect when testing ankle clonus of a healthy woman?
No movement of the foot
Plantar flexion of the foot
Extension of the lower leg
Dorsiflexion of the foot
a.
b.
c.
d.
ANS: A
No movement of the foot is the expected response from a healthy woman. Plantar flexion of
the foot is not a response to ankle clonus. Extension of the lower leg is not a response to ankle
clonus. Dorsiflexion of the foot is an abnormal response of ankle clonus.
DIF: Cognitive Level: Understand
REF: p. 329
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
MULTIPLE RESPONSE
1. To complete a symptom analysis, which questions does a nurse ask patient who recently had a
seizure for the first time? (Select all that apply.)
a. “Did you have any warning signs before the seizure started?”
b. “Did you lose consciousness during the seizure?”
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Health Assessment for Nursing Practice 6th Edition Wilson Test Bank
c.
d.
e.
f.
“Did the room seem to be spinning around before the seizure?”
“Did you urinate during the seizure?”
“What did you hear while you were seizing?”
“How did you feel after the seizure?”
ANS: A, B, D, F
Options A, B, D, and F are all appropriate questions to ask to gather more data about this
patient’s first seizure. “Did the room seem to be spinning around before the seizure?” This
question is about vertigo, which does not relate to this patient. “What did you hear while you
were seizing?” The answer to this question is not needed in the data for this patient.
DIF: Cognitive Level: Analyze
REF: p. 316
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
Systems
2. Which characteristics are risk factors for cerebrovascular accident? (Select all that apply.)
a. Excessive alcohol intake
b. Smoking
c. Eating large amounts of smoked foods
d. Obesity
e. Atherosclerosis
f. High blood pressure
ANS: A, B, D, E, F
Options A, B, D, E, and F are risk factors for cerebrovascular accident. Eating large amounts
of smoked foods is a risk factor for stomach cancer.
N R I G B.C M
U S N REF:
T p. O315
DIF: Cognitive Level: Remember
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: Potential for
Alteration in Body Systems
3. Which manifestations does a nurse correlate with a patient with suspected meningitis? (Select
all that apply.)
a. Ptosis
b. Loss of balance when standing with feet together and the eyes closed
c. Confusion, agitation, and irritability
d. Severe headache
e. Stiff neck
f. Lethargy
ANS: C, D, E, F
Confusion, agitation, and irritability; severe headache this is a symptom of meningeal
irritation due to inflammation of the meninges; stiff neck; lethargy. Patients may have changes
in level of consciousness. Ptosis is drooping of eyelids controlled by the oculomotor cranial
nerve. Loss of balance when standing with feet together and the eyes closed. This describes a
positive Romberg test indicating a cerebellar problem.
DIF: Cognitive Level: Understand
REF: p. 331
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body
NURSINGTB.COM
Health Assessment for Nursing Practice 6th Edition Wilson Test Bank
Systems
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