(Osborn) Chapter 28: Learning Outcomes (Number and Title)

[Osborn] chapter 28
Learning Outcomes [Number and Title]

Learning Outcome 1 Correlate the anatomic and physiological aspects of the
nervous system with the neurological examination.
Learning Outcome 2 Explain the importance of history taking in the
neurological assessment.
Learning Outcome 3 Categorize the cranial nerves with common functional
deficits seen in neurological disease.
Learning Outcome 4 Describe the components of the mental status exam and
methods to complete the assessment.
Learning Outcome 5 Explain the rationale for and methods of measuring and
documenting muscle stretch reflexes.
Learning Outcome 6 Explain the methods of assessing the presence of
pathologic reflexes and the method of documentation.
Learning Outcome 7 Explain the normal age-related differences in the
neurological examination of the elderly patient.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice
Copyright 2010 by Pearson Education, Inc.
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 clients nervous
system?
1.
2.
3.
4.
Parasympathetic
Central
Peripheral
Sympathetic
Correct Answer: Parasympathetic

Rationale: The parasympathetic nervous system is responsible for returning the bodys
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.
Cognitive Level: Applying
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1
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 nurses understanding of the clients
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.
Correct 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 clients concerns rather than directing them to the
health care provider.
Nursing Process: Implementation
LO: 1
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.
2.
3.
4.
Does not include verbal responses.

Requires minimal interaction on the part of the client.
Is designed especially for intensive care unit clients.
Focuses primarily on assessment of cognitive ability.
Correct 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.
Nursing Process: Planning
LO: 1
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 clients priority
intervention is:
1.
2.
3.
4.
Assessment of airway, breathing, and circulation.

Re-assessment using the FOUR Score Consciousness Scale.
Introduction of an intravenous access device.
Establishment of orientation to time, place, and person.
Correct 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. Re-assessment using the FOUR Score Consciousness Scale would not be
a priority since the clients 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.
LO: 2
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.
Correct 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.
LO: 2
6. A nurse is interviewing a client whose wife reports that, hes really forgetting things
more these days. In order to provide the best assessment of this complaint, the nurse
should:
1.
2.
3.
4.
Use the mnemonic OLD CARTS.

Ask the wife to give examples of the clients forgetfulness.
Inquire of the client if he too feels hes forgetful.
Have the client take the Mini-Mental Status Examination (MMSE).
Correct 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 clients alleged forgetfulness.
LO: 2
7. The nurse recognizes that a client with a dysfunctional vagus nerve (CN X) is at risk
for impaired skin integrity related to:
1.
2.
3.
4.
Excessive salivation.
Bells palsy.
Mnires disease.
Tongue deviation.
Correct Answer: Excessive salivation.

Rationale: Vagus nerve (CN X) damage can result in excessive drooling. Bells palsy is a
result of facial nerve (CN VII) dysfunction that causes a drooping of facial muscles.
Mnires 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.
Cognitive Level: Analyzing
LO: 3
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 clients risk
for injury, the nurse should:
1.
2.
3.
4.
Identify the client as a fall risk.

Assess the clients gag reflex prior to offering food or liquids.
Apply an eye bubble to the client at bedtime.
Assess the clients vision using a Snellen chart.
Correct 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)
LO: 3
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.
2.
3.
4.
An abnormal hypoglossal nerve response.

Findings consistent with first cranial nerve damage.
A sluggish oculomotor response.
Pronounced absence of the Homans sign.
Correct 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.
LO: 3
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 husbands
mental status.
2. Its 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 isnt unusual, but this test will rule out any serious problems.
Correct Answer: The test has a few questions that are used to thoroughly assess your
husbands mental status.
Rationale: The Mini-Mental Status Examination (MMSE) is a tool that systematically
assesses a clients 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.
LO: 4
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
clients 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).
Correct 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 Mini-Mental 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.
LO: 4
12. After providing a clients son with an explanation of the function of the Mini-Mental
Status Examination (MMSE), the nurse is confident of the sons understanding when he
states:
1. So this test will evaluate my dads 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. Im sure Dad will do well on the test; hes always been smart.
Correct Answer: So this test will evaluate my dads 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 ones ability to live independently. That
evaluation is not a pass/fail type of testing and does not provide definite proof of mental
wellness. Ones intelligence is not the focus of the evaluation.
Nursing Process: Evaluation
LO: 4
13. While assessing an unconscious clients neurological status, the nurse applies pain by
pinching the sternocleidomastoid muscle. This technique is implemented because:
1.
2.
3.
4.
Pain will make abnormal motor responses observable.

An unconscious clients pain threshold is abnormally high.
Response to pain is an indicator of cognitive function.
The client is most likely to respond to pain at that site.
Correct 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.
LO: 5
14. The nurse recognizes that which of the following assessment observations of a
comatose client has the greatest implication?
1.
2.
3.
4.
Both arms are extended and adducted and with the palms facing down.
Arms, wrist, and fingers are flexed and adducted.
Muscles of the entire upper extremities are flaccid bilaterally.
Fasciculational twitching occurs in the small muscle groups of both arms.
Correct 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.
LO: 5
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.
Correct 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.
LO: 5
16. The nurse recognizes which of the following observations as a positive Babinski
sign?
1.
2.
3.
4.
Dorsiflexion of the great toe, with fanning of the other toes

Curling of all the toes in response to stroking stimulation
Feeling a buzzing sensation in the foot when touched with a tuning fork
Inability to identify two simultaneous points of pain on the foot
Correct 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.
LO: 6
17. When the nurse assesses the clients abdominal superficial reflexes, the umbilicus
moves in the direction of the skin stimulated. The nurse documents this observation as:
1.
2.
3.
4.
A positive (+) response.

A negative (-) response.
An absence of response.
A questionable response.
Correct 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.
LO: 6
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.
2.
3.
4.
5.
Babinski
Grasp
Snout
Sucking
Achilles
Correct 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.
LO: 6
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 nurses 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 nurseclient discussion.
3. Ask that a clients family member be present during the educational session.
4. Arrange for the clients room to be well lighted and quiet during the teaching
session.
Correct 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 clients hearing and visual
deficiencies are not first addressed.
LO: 7
20. The nurse is preparing to administer a Mini-Mental Status Examination (MMSE) on a

75-year-old client admitted for clinical depression. The nurses initial intervention for this
specific client is to:
1.
2.
3.
4.
Plan for the test when the client will not to be rushed to complete it.
Repeat the instructions just prior to beginning the assessment.
Arrange for the client to be uninterrupted during the test.
Make sure the client is not hungry or in pain when taking the test.
Correct 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.
LO: 7
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.
2.
3.
4.
The clients perception of sweetness has become more sensitive.

Sugar substitutes are sweeter than natural sugar.
Diabetes mellitus can alter ones tolerance for sugar.
The client has not adjusted to the use of sugar substitutes.
Correct Answer: The clients 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 ones taste tolerance
for sugar, but rather on the bodys 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.
LO: 7

(Osborn) Chapter 28: Learning Outcomes (Number and Title)

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(Osborn) Chapter 28: Learning Outcomes (Number and Title)

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[Osborn] chapter 28

Learning Outcomes [Number and Title]

1. A client experiencing extreme emotional stress is observed to be exhibiting both

Correct Answer: Parasympathetic

Does not include verbal responses.

Correct Answer: Does not include verbal responses.

Assessment of airway, breathing, and circulation.

Correct Answer: Assessment of airway, breathing, and circulation.

Use the mnemonic OLD CARTS.

Correct Answer: Use the mnemonic OLD CARTS.

Correct Answer: Excessive salivation.

Identify the client as a fall risk.

Correct Answer: Identifying the client as a fall risk.

An abnormal hypoglossal nerve response.

Correct Answer: An abnormal hypoglossal nerve response

Pain will make abnormal motor responses observable.

Correct Answer: Pain will make abnormal motor responses observable.

Dorsiflexion of the great toe, with fanning of the other toes

A positive (+) response.

Correct Answer: A positive (+) response.

20. The nurse is preparing to administer a Mini-Mental Status Examination (MMSE) on a

The clients perception of sweetness has become more sensitive.

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