Nokea
A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI(11) is intact when the client performs which of the following actions?
- A. Shrugs his shoulders
- B. Smiles symmetrically
- C. Closes his eyes tightly
- D. Identifies a familiar scent
Correct Answer: A
Rationale: The correct answer is A: Shrugs his shoulders. Cranial nerve XI, also known as the accessory nerve, controls the movement of the trapezius and sternocleidomastoid muscles, which are responsible for shoulder shrugging. By asking the client to shrug his shoulders, the nurse can assess the integrity of cranial nerve XI.
Choices B, C, and D are incorrect because they are associated with other cranial nerves. Smiling symmetrically is controlled by cranial nerve VII (facial nerve), closing eyes tightly is controlled by cranial nerve V (trigeminal nerve), and identifying a familiar scent is related to cranial nerve I (olfactory nerve).
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which of the following findings should the nurse recognize as an expected finding?
- A. The anterior fontanel is open
- B. The posterior fontanel is open
- C. The anterior fontanel is sunken
- D. The anterior fontanel is bulging
Correct Answer: A
Rationale: The correct answer is A: The anterior fontanel is open. This is an expected finding in infants as the anterior fontanel typically remains open until around 18-24 months of age, allowing for the growth and expansion of the skull bones. It is a normal part of development and closure indicates maturation. The posterior fontanel closes earlier than the anterior fontanel, so option B is incorrect. Option C, sunken anterior fontanel, indicates dehydration, while option D, bulging anterior fontanel, is a sign of increased intracranial pressure, both of which are abnormal findings.
Which of the following findings should the nurse report to the provider?
- A. Abdominal pain
- B. Belching
- C. Fatulence
- D. Sore throat
Correct Answer: A
Rationale: The correct answer is A: Abdominal pain. Abdominal pain is a significant finding that could indicate underlying health issues and requires immediate attention from the provider for further assessment and intervention. Belching and flatulence are common gastrointestinal symptoms that may not necessarily warrant immediate reporting. Sore throat, unless severe or persistent, can often be managed with over-the-counter remedies. It is important to prioritize reporting symptoms that could be indicative of serious conditions to ensure timely and appropriate care.
Nurse reviews the assessment findings. Which findings require immediate follow-up?
- A. Right forearm and fingers are edematous.
- B. Ecchymotic area noted on outer aspect of the forearm.
- C. Heart rate 102/min
- D. Fingers slightly cool to touch.
- E. Child verbalizes a pain level of 4 on a scale of 0 to 10
- F. Respiratory rate 22/min
Correct Answer: A,D
Rationale: Edema and coolness in the extremity suggest circulatory impairment, warranting immediate attention.
Which finding should the nurse identify as a potential indication of increased intracranial pressure?
- A. Increasingly severe headache
- B. Bradycardia and hypertension
- C. Dilated, non-reactive pupils
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D, "All of the above." Increasingly severe headache is a common symptom of increased intracranial pressure due to brain tissue compression. Bradycardia and hypertension can occur as a result of increased intracranial pressure affecting the autonomic nervous system. Dilated, non-reactive pupils may indicate brainstem compression. Therefore, all of these findings are potential indications of increased intracranial pressure. Choices A, B, and C all individually point towards different manifestations of increased intracranial pressure, making them incorrect if considered in isolation.
Which of the following should the nurse use to assess the port?
- A. An Angio catheter
- B. A butterfly needle
- C. A noncoring needle
- D. A 25-gauge needle
Correct Answer: C
Rationale: The correct answer is C: A noncoring needle. To assess a port, a noncoring needle should be used because it is specifically designed for accessing ports without damaging the septum. Using an Angio catheter (A) may be too large and cause damage, a butterfly needle (B) is not suitable for accessing ports, and a 25-gauge needle (D) may be too small or not specifically designed for port access. Noncoring needles are the standard choice for accessing ports due to their design that minimizes trauma and ensures proper function.