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:

CN V

CN XII

CN VII

CN I

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is D

Explanation

A. While isolation may be necessary in certain situations to ensure safety, it is not the most critical
intervention. It’s essential to balance safety with providing the client with support and not making them feel isolated or abandoned. The primary focus should be on creating a safe environment and addressing the immediate risk of self-harm.
B. Checking on the client every 4 hours may not be frequent enough for a client who is at risk of self- harm or suicide. More frequent monitoring is typically required, especially if the client is deemed at high risk. Immediate and continuous observation is often necessary to prevent further attempts.
C. While setting boundaries is important for therapeutic interactions, it is secondary to addressing immediate safety concerns. The primary focus should be on preventing self-harm and ensuring a safe environment rather than just enforcing rules.
D. Providing a safe environment by removing items that could cause harm is the most crucial intervention for a client who has attempted suicide. This step directly addresses the risk of self-harm and helps prevent further suicide attempts. Creating a safe environment is a fundamental aspect of suicide prevention and immediate care.

A. The patient demonstrates Flight of ideas B. demonstrates confabulation C. depressed D. demonstrates schizophrenia

Correct Answer is A

Explanation

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.

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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:

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Naxlex Comprehensive Predictor Exams

When implementing nursing interventions for a client who has attempted suicide, which of the following is most important?

Correct Answer is D

Explanation

The nurse is admitting a client to the unit for surgery the next morning. The nurse notes that the client speaks at an accelerated pace and jumps from topic to topic no of which progresses to sensible conversation. What would the nurse document about this client?

Correct Answer is A

Explanation

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