A nurse is conducting a health history with a client who has recently had a stroke. The nurse notes the client is unable to speak, although his comprehension/ understanding is intact. Which disorder of speech is the nurse observing in this client?

Expressive Aphasia

Aphonia

Receptive Aphasia

Dysphonia

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is B

Explanation

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. Verbal respond B. Motor respond C. Pupillary responds D. Gag Reflex E. Eye Opening

Correct Answer is ["A","B"]

Explanation

A. The verbal response is one of the three components of the Glasgow Coma Scale. It assesses the patient's ability to speak and respond appropriately to questions, indicating their level of consciousness. Responses are scored based on clarity, coherence, and relevance.
B. Motor response is another component of the Glasgow Coma Scale. It evaluates the patient’s ability to move in response to stimuli, including purposeful movements, localizing pain, or abnormal posturing. The motor response helps gauge the patient’s level of consciousness and neurological function.
C. Pupillary response refers to how the pupils react to light and changes in size. While important in neurological assessments, it is not one of the three components of the Glasgow Coma Scale. Pupillary response is assessed separately from the GCS but provides additional information about brain function and potential injury.
D. The gag reflex is a protective mechanism to prevent choking and is assessed by stimulating the back of the throat. It is not included in the Glasgow Coma Scale. The GCS focuses on eye opening, verbal response, and motor response rather than reflexes.
E. Eye opening is the third component of the Glasgow Coma Scale. It assesses the patient’s ability to open their eyes spontaneously or in response to stimuli. This component helps determine the level of consciousness and alertness.

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A nurse is conducting a health history with a client who has recently had a stroke. The nurse notes the client is unable to speak, although his comprehension/ understanding is intact. Which disorder of speech is the nurse observing in this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a physical examination on a patient. When the patient is asked to protrude his tongue, the nurse noticed a deviation from the midline to the right side. This is related to a lesion of:

Correct Answer is B

Explanation

Which are the 3 areas included in the Glasgow Coma Scale to assess levels of consciousness? Select all that Apply.

Correct Answer is ["A","B"]

Explanation

A client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding?

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Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve?

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