Which clinical indicator would the nurse expect to find when assessing a client with hemiplegia

The nurse assesses for damage to the glossopharyngeal (ninth cranial) and vagus (tenth cranial) nerves. Which action will the nurse ask the client to perform?
1
Shrug
2
Smell
3
Smile
Correct 4
Swallow
Having the client swallow or checking the gag reflex is a test of cranial nerves IX and X. Shrugging tests the accessory nerve ( cranial nerve XI). The sense of smell tests the olfactory nerve (cranial nerve I). Smiling tests the facial nerve (cranial nerve VII).
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2.
When a nurse requests that a client's pain intensity be rated on a scale of 0 to 10, the client states that the pain is "99." How does the nurse interpret the client's behavior?
1
Needs the instructions to be repeated
Correct 2
Requires an intervention immediately
3
Does not understand the numeric scale
4
Is using humor to get the nurse's attention
The client reported a number as instructed but chose a number beyond the stated intensity scale. When numbers above 10 are identified, clients are communicating that the pain is excessive; immediate nursing action is indicated. It is not likely that the client misunderstood the instructions or does not understand the numeric scale; the client reported a number as instructed but chose a number beyond the stated intensity scale. The client has the nurse's attention; the use of humor is not commonly associated with clients in pain.

Test-Taking Tip: If the question asks for an immediate action or response, all of the answers may be correct, so base your selection on identified priorities for action.
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3.
The nurse is performing a neurologic assessment on a client and is completing the Glasgow Coma Scale (GCS). What components make up this assessment tool? Select all that apply.
Correct 1
Best verbal response
2
Best pupillary response
Correct 3
Best motor response
Correct 4
Best eye-opening response
5
Best cognitive response
The GCS [1] [2] is a common way of determining and documenting level of consciousness that scores verbal response, motor response, and eye-opening response. The lowest score is 3, which indicates a totally unresponsive client; a normal GCS score is 15. Pupillary and cognitive responses are not part of the GCS assessment.

Test-Taking Tip: Look for answers that focus on the client or that are directed toward the client's feelings.
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4.
A healthcare provider determines that a client has myasthenia gravis. Which clinical findings does the nurse expect when completing a health history and physical assessment? Select all that apply.
Correct 1
Double vision
2
Problems with cognition
Correct 3
Difficulty swallowing saliva
4
Intention tremors of the hands
Correct 5
Drooping of the upper eyelids
6
Nonintention tremors of the extremities
Double vision occurs as a result of cranial nerve dysfunction. Facial muscles innervated by the cranial nerves often are affected; difficulty with swallowing (dysphagia) is a common clinical finding. Drooping of the upper eyelids (ptosis) occurs because of cranial nerve III (oculomotor) dysfunction. Myasthenia gravis is a neuromuscular disease with lower motor neuron characteristics, not central nervous system symptoms. Intention tremors of the hands are associated with multiple sclerosis. Nonintention tremors of the extremities are associated with Parkinson disease.
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5.
A nurse is performing a neurologic assessment of a client. Which equipment is required when preparing to assess the vagus nerve (cranial nerve X) of the client?
1
Tuning fork
2
Ophthalmoscope
Correct 3
Tongue depressor
4
Cotton and a straight pin
A tongue depressor is used to depress the tongue to observe the pharynx and larynx, and to assess soft palate symmetry and the presence of the gag reflex; the information obtained provides data about cranial nerve X (vagus). A tuning fork is used to assess cranial nerve VIII (auditory). An ophthalmoscope is used to assess cranial nerve II (optic). Cotton and a straight pin are used to assess sensory function: light touch and pain.
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6.
After an automobile collision, a client who sustained multiple injuries is oriented to person and place but is confused to time. The client complains of a headache and drowsiness, but assessment reveals that the pupils are equal and reactive. Which nursing action takes priority?
1
Moving the client as little as possible
2
Preparing the client for mannitol administration
3
Stimulating the client to maintain responsiveness
Correct 4
Monitoring the client for increasing intracranial pressure
Limiting increasing intracranial pressure [1] [2] and resulting brain damage depends on frequent, systematic assessments to identify this complication early. There is no indication that movement should be restricted. Mannitol is administered to reduce cerebral edema; there is no indication at this time that this is needed. Stimulating the client to maintain responsiveness is unrealistic; the state of consciousness should be monitored, but otherwise rest is not contraindicated.

Test-Taking Tip: Note the number of questions and the total time allotted for the test to calculate the times at which you should be halfway and three-quarters finished with the test. Look at the clock only every 10 minutes or so.
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7.
The nurse evaluates that the teaching about myasthenic and cholinergic crises is understood when a client who is diagnosed with myasthenia gravis states that which characteristic is common to both crises?
1
Diarrhea
2
Salivation
Correct 3
Difficulty breathing
4
Abdominal cramping
Because of the decrease in tone and strength of the respiratory muscles, difficulty breathing is a prominent feature of both crises. Diarrhea occurs in cholinergic crisis; it is an effect of an overdose of the medications (anticholinesterases) used to treat myasthenia gravis. Salivation occurs in cholinergic crisis; it is an effect of an overdose of the medications (anticholinesterases) used to treat myasthenia gravis. Abdominal cramping occurs in cholinergic crisis; it is an effect of an overdose of the medications (anticholinesterases) used to treat myasthenia gravis.
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8.
After a mild brain attack (cerebrovascular accident, CVA) a client has difficulty grasping objects with the dominant hand. To increase hand mobility and strength, what specific range-of-motion exercise should the nurse teach the client?
1
Eversion
2
Supination
Correct 3
Opposition
4
Circumduction
Opposition occurs when the thumb, a saddle joint, sequentially touches the tip of each finger of the same hand; the thumb joint movements involved are abduction, rotation, and flexion. Strengthening the thumb facilitates grasping and holding objects in the hand. Eversion involves turning the sole of the foot outward by moving the ankle joint, which is a gliding joint. Supination involves moving the bones of the forearm so that the palm of the hand faces upward when held in front of the body. Circumduction involves movement of the distal part of the bone in a circle while the proximal end remains fixed; circumduction is used with ball-and-socket joints, such as the shoulder and hip.

Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.
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9.
A nurse performs a Rinne test during physical assessment of a client. The client indicates that the sound is louder when the vibrating tuning fork is placed against the mastoid bone than when held closely to the ear. What conclusion should the nurse make about these results?
1
This represents an expected finding.
2
The client may have a sensorineural deficit.
Correct 3
This is evidence of a conductive hearing loss.
4
The client has an inflammation of the mastoid.
Conductive hearing loss [1] [2] involves impaired transmission of sound waves to the inner ear so that sound transmitted directly through bone is perceived louder and longer than through air conduction. Clients with normal hearing or sensorineural deficit perceive air conduction of sound waves louder and longer than bone conduction. The Rinne test is not related to inflammation of the mastoid.
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10.
Bed rest is prescribed after a client's cerebrovascular accident (CVA, "brain attack") results in right hemiplegia. Which exercises should the nurse incorporate into the client's plan of care 24 hours after the brain attack?
Correct 1
Passive range-of-motion exercises
2
Active exercises of the extremities
3
Light weight-lifting exercises of the right side
4
Isotonic exercises that will capitalize on returning muscle function
Passive range-of-motion exercises prevent the development of deformities (e.g., contractures) and do not require any energy expenditure by the client. Instituting range-of-motion exercises is an independent nursing function. The client will be unable to perform active exercises and weight-lifting. Isotonic exercises are active movement, which the client is unable to do.

Which clinical finding is the nurse most likely to identify on a client who is diagnosed with myasthenia gravis?

Which assessment finding would the nurse document in the client's health record as positive Romberg test?

How should a nurse assess a client's trigeminal nerve function?

Which criteria would the nurse use to assess the mental status of a patient select all that apply quizlet?