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 A

Explanation

Choice A reason: Thick, white plaques suggest oral thrush, often Candida, linked to HIV immunosuppression. Facilitating HIV testing addresses a potential underlying cause, as CD4 decline allows opportunistic infections, making this the critical next step for diagnosis and management here.

Choice B reason: Referral for medication treats thrush symptomatically but misses underlying HIV risk. Antifungals help, yet without addressing immunosuppression, recurrence persists, making this less urgent than testing for a systemic condition driving the plaques in this scenario fully.

Choice C reason: Jaundice causes yellowing, not white plaques, which are fungal, not hepatic. Assessing for this misaligns with the finding’s etiology, as thrush ties to immunity, not liver function, rendering it irrelevant to the client’s oral presentation entirely here.

Choice D reason: Zinc deficiency causes taste loss or ulcers, not thick plaques like thrush. Lab review for this overlooks the infectious, possibly HIV-related cause, missing the immunological context critical to addressing the client’s specific oral condition accurately and promptly.

A. The jugular venous pulse is visible when the client lies supine. B. The jugular veins are distended when the client sits at a 45-degree angle. C. The jugular venous pulse is not visible when the client is sitting upright. D. The jugular veins are fully distended when the client is in a high Fowler position.

Correct Answer is C

Explanation

Choice A reason: Visible jugular pulse supine is normal, as gravity pools venous blood. However, the question seeks upright findings. This is expected lying down, not sitting, misaligning with the healthy standard for an upright position in this context fully.

Choice B reason: Distended jugular veins at 45 degrees suggest elevated central venous pressure, like in heart failure, not health. In a healthy client, veins collapse at this angle, making this an abnormal, not expected, finding for jugular assessment here.

Choice C reason: No visible jugular pulse upright is normal in health, as venous pressure drops below the clavicle when sitting. This reflects proper heart function and gravity’s effect, aligning with expected findings in a healthy client’s neck vessel exam accurately.

Choice D reason: Full jugular distension in high Fowler’s (60-90 degrees) indicates pathology, like right heart failure, not health. Healthy veins collapse at this elevation, making this an abnormal finding, not the expected norm for jugular assessment entirely here.

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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 assesses thick, white plaques on a client's tongue and hard palate. Which of the following nursing actions should the nurse do next?

Correct Answer is A

Explanation

The nurse has begun the objective assessment of a client's heart and neck vessels and is assessing the client's jugular veins. What finding would the nurse consider to be expected in a healthy client?

Correct Answer is C

Explanation

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