A client with a wide-based, staggering, unsteady gait walks into the clinic. The gait would be correctly described as which of the following?

Cerebral stagger

Scissors gait

Parkinsonian gait

Cerebellar ataxia

Answer and Explanation

The Correct Answer is D

Choice A reason: Cerebral stagger isn’t a standard term; cerebral damage might cause spasticity, not wide-based ataxia. This lacks specificity for cerebellar signs like staggering, misaligning with the broad, unsteady gait tied to coordination loss in this client fully.
Choice B reason: Scissors gait, from cerebral palsy, shows stiff, crossed legs, not wide-based staggering. This spastic pattern contrasts with the unsteady, broad stance of cerebellar dysfunction, excluding it as the correct description for this presentation entirely here.
Choice C reason: Parkinsonian gait is shuffling with small steps and rigidity, not wide-based or staggering. This contrasts with the unsteady, broad stance of cerebellar ataxia, making it an incorrect match for the client’s observed walking pattern fully here.
Choice D reason: Cerebellar ataxia causes a wide-based, staggering gait due to coordination loss from cerebellar damage. This matches the client’s unsteady walk, reflecting impaired balance and motor control, accurately describing the observed gait pattern comprehensively here.

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Correct Answer is B

Explanation

Choice A reason: Family history suggests dementia, not delirium. Dementia progresses slowly, unlike delirium’s acute onset, making this less indicative of the sudden cognitive shift typical of delirium, especially without a rapid trigger in this case fully here.
Choice B reason: New medication often causes delirium in older adults via anticholinergic effects or toxicity. This acute, reversible change aligns with delirium’s hallmark sudden onset, making it the most suggestive finding for this cognitive impairment accurately here.
Choice C reason: Decline over months to a year fits dementia, not delirium. Delirium is acute, not chronic, excluding this gradual progression as a sign of the rapid cognitive shift delirium presents in this assessment entirely and fully.
Choice D reason: Hypertension risks vascular dementia, not delirium. It’s a chronic factor, not an acute trigger, missing delirium’s sudden, reversible nature tied to immediate causes like drugs, rendering it less relevant here comprehensively and clearly.

A. "Clench your teeth together tightly." B. "Open your mouth wide and say 'ah.'" C. "Look at me while I shine this light in your eye." D. "Close your left eye and look at me with your right eye."

Correct Answer is A

Explanation

Choice A reason: Clenching teeth tests cranial nerve V’s motor branch, innervating mastication muscles like the masseter. This assesses strength and symmetry, directly evaluating trigeminal function, making it the precise instruction for this nerve’s motor assessment accurately here.
Choice B reason: Opening the mouth and saying “ah” tests cranial nerves IX and X, not V. This assesses gag reflex and palate movement, missing the trigeminal’s role in jaw strength, rendering it irrelevant to this specific nerve exam fully.
Choice C reason: Shining light in the eye tests cranial nerves II and III, not V. This checks pupil response, unrelated to trigeminal sensory or motor functions, excluding it from the assessment of jaw and facial sensation entirely here.
Choice D reason: Closing one eye and looking tests cranial nerves III, IV, and VI, not V. This evaluates eye movement, not trigeminal innervation of facial muscles or sensation, disconnecting it from the intended cranial nerve assessment fully here.

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A client with a wide-based, staggering, unsteady gait walks into the clinic. The gait would be correctly described as which of the following?

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Naxlex Comprehensive Predictor Exams

An older adult client has been admitted due to decreased cognition. What assessment finding is most suggestive of delirium as the cause of the client's cognitive impairment?

Correct Answer is B

Explanation

The nurse is assessing cranial nerve 5 (the trigeminal nerve) in a newly admitted client. What instruction should the nurse provide to the client during this phase of the assessment?

Correct Answer is A

Explanation

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