A. The soft palate should move during phonation. If it remains stationary, it could indicate a problem with cranial nerves IX and X. These nerves control the movement of the soft palate and the muscles involved in phonation.
B. This is the normal finding. During the assessment, when the patient says "ah," the uvula and soft palate should rise symmetrically. This movement indicates that cranial nerves IX and X are functioning properly. If the uvula and soft palate rise bilaterally, it means that both sides of the soft palate are being controlled correctly by these nerves.
C. Asymmetry in the soft palate could indicate dysfunction of cranial nerves IX and X. Normally, the soft palate should rise evenly on both sides when the patient says "ah." An asymmetrical soft palate suggests that one side is not functioning correctly, which may be due to nerve damage or weakness.
D. This is not a normal finding. If the uvula deviates to one side when the patient says "ah," it indicates a problem with the function of the cranial nerves. The deviation is usually towards the side opposite to the weak or affected side. This asymmetry in uvula movement can be due to a weakness or paralysis of the muscles on one side controlled by these nerves.

A. Expressive aphasia (also known as Broca’s aphasia) is a condition where the individual has difficulty producing speech or writing, despite having relatively intact comprehension and awareness of their

communication difficulties. This condition often results from damage to Broca’s area in the left frontal lobe of the brain
B. Aphonia refers to the loss of voice or the inability to produce vocal sounds. It is typically associated with a physical issue affecting the vocal cords or larynx, such as vocal cord paralysis or severe laryngitis. Aphonia does not necessarily affect comprehension or the ability to understand speech, but rather the ability to produce sound.
C. Receptive aphasia (also known as Wernicke’s aphasia) is characterized by difficulty understanding or processing language, despite fluent speech production. Individuals with receptive aphasia often speak in long sentences that lack meaning or include incorrect or nonsensical words, and they have impaired comprehension
D. Dysphonia refers to difficulty in producing speech due to issues with the voice, such as hoarseness or discomfort, often related to vocal cord problems. While it affects the quality of the voice, it does not necessarily impact the ability to understand language or produce speech in a meaningful way. Dysphonia is not the correct choice for the scenario described.

A. The trigeminal nerve (CN V) primarily controls sensation in the face and the muscles of mastication (chewing). While it is crucial for sensory input and motor control related to chewing, it does not directly control the movement of the tongue.
B. The hypoglossal nerve (CN XII) is responsible for controlling the movements of the tongue. A lesion of CN XII can cause the tongue to deviate towards the side of the weakness or damage. This is because the hypoglossal nerve innervates the muscles of the tongue, and damage to it results in weakness of the muscles on the affected side, causing the tongue to deviate towards that side when protruded.
C. The facial nerve (CN VII) controls the muscles of facial expression. While it affects facial movements and expressions, it does not control the movements of the tongue. A lesion in CN VII would typically result in facial asymmetry or weakness rather than tongue deviation.
D. The olfactory nerve (CN I) is responsible for the sense of smell. It does not have any role in controlling tongue movement. Therefore, a lesion in CN I would not cause deviation of the tongue.

A. Blurred vision is generally associated with visual system issues, which involve the occipital lobe or the visual pathways rather than the frontal lobe. Broca’s area, located in the frontal lobe, is involved in speech production and not in vision processing.
B. Difficulty speaking is a key symptom associated with damage to Broca’s area, which is located in the frontal lobe and responsible for speech production. A contusion in this area can lead to expressive aphasia, where the individual has trouble forming grammatically correct sentences and articulating words, while comprehension remains relatively intact.
C. Loss of tactile sensation would generally be associated with damage to the parietal lobe, where the primary somatosensory cortex is located. The parietal lobe processes sensory information such as touch, temperature, and pain. Since Broca’s area is located in the frontal lobe and primarily deals with language production, loss of tactile sensation is not typically expected from a frontal lobe contusion affecting Broca's area.
D. Inability to hear high-pitched sounds relates to issues with the auditory pathways or structures involved in hearing, such as the temporal lobe or the auditory cortex, not the frontal lobe. The frontal lobe and Broca’s area do not directly control auditory perception.

A. muscle strength grade of 3 indicates that the client can move the arm (or other limb) against gravity but not against any additional resistance. In this case, if the client is able to actively move the right arm against gravity, this is a correct grading. The ability to move the arm against gravity alone aligns with a grade of 3.
B. A muscle strength grade of 2 indicates that the client can move the arm (or other limb) only with gravity eliminated. This means that the client can move the limb when it is placed in a horizontal position but not against gravity. Since the client can move the arm against gravity, this grade is not applicable.
C. A muscle strength grade of 1 indicates that there is muscle contraction but no movement of the limb. This means there is some visible muscle activity but insufficient to cause any joint movement. Since the client is able to move the arm actively against gravity, this grade does not fit the observed finding.

D. A muscle strength grade of 5 indicates normal strength, where the client can move the limb against gravity and against full resistance. If the client can move the right arm against gravity but not necessarily against full resistance, this is not indicative of a grade of 5. The grade of 5 would be reserved for when the muscle can move against full resistance without difficulty.

A. A grade of 4/5 indicates that the patient can move the upper arms against gravity and can tolerate some resistance. This aligns with the description of the patient being able to move the arms against gravity and some resistance. A grade of 4 suggests that the strength is less than normal but still functional.
B. A grade of 2/5 means the patient can move the arms only with gravity eliminated, meaning they can move the arm when it is in a horizontal position but not against gravity. Since the patient can move the arms against gravity and some resistance, this grade is too low.
C. A grade of 5/5 indicates normal strength, where the patient can move the arm against full resistance with no difficulty. The description states that the patient can move the arms against gravity and some resistance, but not necessarily against full resistance, so 5/5 might be too high of a grade in this case.
D. A grade of 0 indicates no muscle contraction or movement at all. This grade would not apply since the patient is able to move the arms against gravity and some resistance.

A. This test assesses the function of the oculomotor nerve (CN III), not the trigeminal nerve. The oculomotor nerve controls the constriction and dilation of the pupils, as well as some eye movements. Therefore, this choice is not appropriate for assessing the trigeminal nerve.
B. This test assesses the sensory function of the trigeminal nerve (CN V). The trigeminal nerve provides sensation to the face, and testing the ability to differentiate between sharp and dull sensations evaluates

the sensory component of this nerve. However, this test does not assess the motor function of the trigeminal nerve.
C. This test evaluates the motor function of the trigeminal nerve. The trigeminal nerve controls the muscles involved in chewing, including the temporal and masseter muscles. By palpating these muscles while the client clenches their teeth, the nurse assesses the strength and function of these muscles, which are innervated by the trigeminal nerve. This is a direct test of motor function for CN V.
D. This test assesses the function of the facial nerve (CN VII), which controls the muscles of facial expression. It is not relevant for assessing the trigeminal nerve, which is involved in both sensory functions of the face and motor functions related to chewing.

A. Concentration refers to the ability to focus on a specific task or thought for a period of time. While concentration is important for cognitive functioning, it is not the specific skill being assessed when interpreting the meaning of a proverb.
B. Attention is the ability to focus and direct mental resources towards a specific task or stimulus. While attention is necessary for understanding and processing information, the task of interpreting a proverb is more related to higher-level cognitive processes rather than just the ability to maintain focus.
C. Affect refers to the emotional state or mood of a person. It involves how emotions are expressed and experienced. Assessing affect involves observing the client’s emotional responses, not their ability to interpret abstract concepts. Therefore, affect is not the focus of this assessment.
D. Abstract reasoning is the ability to understand and interpret concepts and ideas that are not directly observable or tangible. It involves thinking beyond concrete facts to understand underlying meanings, patterns, and relationships. Interpreting a proverb, which involves understanding a figurative meaning rather than a literal one, is a test of abstract reasoning. The ability to grasp the deeper meaning behind “A penny saved is a penny earned” reflects the client's capacity for abstract reasoning.

A. Flight of ideas is characterized by a rapid and continuous flow of thoughts where the individual frequently shifts topics, often making it difficult to follow their conversation. This is commonly observed in conditions like mania or hypomania, often seen in bipolar disorder.
B. Confabulation involves fabricating or inventing stories or information to fill in gaps in memory. It is often seen in conditions affecting memory or cognition, such as Korsakoff’s syndrome or certain types of dementia.
C. Depression typically involves symptoms such as low mood, decreased energy, and lack of interest in activities, rather than rapid speech or topic shifts. The client’s accelerated pace of speech and jumping from topic to topic do not align with the characteristics of depression.
D. Schizophrenia is a broad term for a range of symptoms, including hallucinations, delusions, disorganized thinking, and impaired social functioning. While disorganized thinking can be a symptom of schizophrenia, the specific behavior described (accelerated speech and jumping topics) more specifically indicates flight of ideas, which is not exclusive to schizophrenia.

A. Extinction refers to the phenomenon where a person fails to recognize a stimulus on one side of the body when another stimulus is presented simultaneously on the opposite side. This is often tested in cases of neurological impairment, particularly in the context of sensory neglect or loss
B. Stereognosis is the ability to identify an object by touch and proprioception without visual input. It involves recognizing the shape, size, and texture of an object solely through tactile information. Placing a coin in the patient’s hand and asking them to identify it with their eyes closed tests their ability to use tactile information to recognize objects, making stereognosis the correct term for this assessment.
C. Proprioception is the sense of the position and movement of the body and its parts. It involves awareness of body position in space, which is crucial for coordination and balance. While important, proprioception does not specifically involve identifying objects by touch alone; it is more about the awareness of body position.
D. Two-point discrimination is the ability to distinguish between two closely spaced points of contact on the skin. It tests the sensitivity of the skin to touch and is often used to assess sensory nerve function. It does not involve identifying objects by touch but rather measuring how well one can discern between two separate points of contact.