A nurse is working with a client who has a history of headaches for greater than two months. When preparing to assess the client's temporomandibular joint, what instruction provided to the client would indicate the nurse needs more teaching?

"I am going to place my hand on your cheek, and I want you to turn your head against resistance."

"I’m going to place my fingers in front of your ear, and I want you to open your mouth as wide as possible."

"I want you to move your jaw from side to side and tell me if there is any pain with the movement."

"Push out and pull in your lower jaw and let me know if you experience popping or grating."

Answer and Explanation

The Correct Answer is A

Choice A reason: Turning the head against resistance assesses neck muscles, not the temporomandibular joint (TMJ), which hinges the jaw. TMJ evaluation requires jaw-specific movements, not cervical rotation, indicating a misunderstanding of TMJ anatomy and function, misaligning with headache assessment needs.

Choice B reason: Opening the mouth wide while fingers are placed near the ear directly tests TMJ range of motion and joint integrity. This is a standard technique to detect dysfunction or pain, correctly targeting the jaw’s articulation point relevant to headaches.

Choice C reason: Moving the jaw side to side evaluates TMJ lateral excursion, a key diagnostic motion. Pain reporting during this action helps identify joint issues tied to chronic headaches, making it an appropriate and precise instruction for TMJ assessment.

Choice D reason: Pushing out and pulling in the jaw tests TMJ protrusion and retraction, critical for assessing joint stability and sounds like popping, which may link to headache etiology. This instruction correctly focuses on TMJ mechanics and symptoms.

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Correct Answer is D

Explanation

Choice A reason: Impaired judgment suggests frontal lobe pathology, like dementia, not normal aging. Age-related changes slow processing, not executive function, making this a disease sign, not a typical neurological shift in an 81-year-old fully here.
Choice B reason: Loss of remote memory indicates Alzheimer’s, not normal aging. Aging may slow recall, but long-term memory typically persists, excluding this as an expected age-related change in this neurological assessment entirely and accurately here.
Choice C reason: Intention tremors signal cerebellar disease, like Parkinson’s, not aging. Normal aging may reduce fine motor speed, but not cause action tremors, distinguishing this as pathological, not a standard age-related finding fully here.
Choice D reason: Reduced distal sensation, from nerve conduction slowing, is a common age-related change. Aging thins myelin, impairing peripheral nerves, making this the expected finding in an 81-year-old’s neurological exam accurately and comprehensively here.

A. A 55-year-old client with hyperthyroidism B. A 30-year-old client who drinks a beer twice a week C. A 75-year-old client who has smoked for 50 years D. A 40-year-old with arteriosclerosis

Correct Answer is C

Explanation

Choice A reason: Hyperthyroidism may cause eye issues like exophthalmos, not cataracts. Lens opacity from aging or smoking outweighs thyroid risk, making this 55-year-old less prioritized for cataract screening than older, smoking-exposed clients in this context fully.
Choice B reason: Minimal alcohol (two beers weekly) at 30 poses no cataract risk. Age and smoking are stronger factors; this young client lacks the cumulative exposure or oxidative stress tied to lens clouding, excluding them entirely here.
Choice C reason: At 75, with 50 years of smoking, this client faces high cataract risk. Aging degrades lens proteins, and smoking’s oxidative damage accelerates opacity, making this the priority for assessment and education on cataract prevention accurately here.
Choice D reason: Arteriosclerosis at 40 affects vessels, not lenses directly. While vascular health matters, age and smoking outweigh this risk for cataracts, rendering this client lower priority than the older, heavily smoking individual in this scenario fully.

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A nurse is working with a client who has a history of headaches for greater than two months. When preparing to assess the client's temporomandibular joint, what instruction provided to the client would indicate the nurse needs more teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is conducting a focused neurologic assessment on an 81-year-old client. What finding below is an age-related neurologic change?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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A nurse is working with a client who has a history of headaches for greater than two months. When preparing to assess the client's temporomandibular joint, what instruction provided to the client would indicate the nurse needs more teaching?

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