After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? Select all that apply.

Asked the client to swallow

Asked the client to extend the tongue

Asked the client to rock the jaw laterally

Asked the client to open and close the mouth

Asked the client to jut the jaw forward

Answer and Explanation

Correct Answer : C,D,E

A.   Swallowing involves the muscles of the throat and esophagus rather than the TMJ.
B.   Extending the tongue involves the muscles of the tongue and mouth, which are not directly related to the TMJ.
C.   Rocking the jaw laterally (side to side) is a specific movement that involves the TMJ. This movement tests the ability of the TMJ to move the jaw from side to side.
D.   Opening and closing the mouth involves the primary hinge movement of the TMJ. This movement assesses the vertical range of motion of the jaw.
E.   Jutting the jaw forward (protrusion) involves moving the lower jaw forward in relation to the upper jaw. This movement tests the ability of the TMJ to perform anterior movement.

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Correct Answer is A

Explanation

A. 3- This is the lowest possible score on the GCS and reflects no eye opening, no verbal response, and no motor response to stimuli. Score of 4-6: The patient might exhibit some responses, but these responses are still severely impaired. For example, the patient might open their eyes to pain but not respond verbally or move purposefully.
B. A GCS score in the range of 13 to 15 reflects a higher level of consciousness.
C. A GCS score of 0 is not a valid score on the scale.
D. A GCS score in the range of 9 to 12 reflects moderate impairment of consciousness.

A. CN V B. CN XII C. CN VII D. CN I

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.

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After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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