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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. In the Mini-Cog assessment, the inability to recall the three words (which tests short-term memory) while still being able to draw a clock (which tests visuospatial skills) could suggest early cognitive impairment or dementia. Dementia often presents with deficits in memory but may retain some other cognitive functions, like drawing. The result is consistent with a possible diagnosis of dementia, especially if memory issues are noted over time.
B. A delusion is a false belief held despite evidence to the contrary. Delusions are more related to psychiatric disorders and are not primarily assessed by the Mini-Cog. The Mini-Cog does not assess for delusions but rather focuses on cognitive function.
C. Depression can affect cognitive function, sometimes resulting in difficulties with concentration, memory, and other cognitive tasks. While depression can cause cognitive symptoms, it typically presents with other signs such as changes in mood, loss of interest in activities, and changes in sleep patterns.
D. Delirium is an acute, fluctuating change in cognition and attention, often caused by an underlying medical condition, medication, or intoxication. Delirium is characterized by rapid onset and fluctuating levels of consciousness and attention, which is not consistent with the Mini-Cog results showing stable performance on the clock drawing but poor recall.
Correct Answer is B
Explanation
A. Coma is a state of profound unconsciousness where the patient cannot be awakened and does not respond to any stimuli, including verbal commands or physical stimuli.
B. Lethargy is characterized by a state of drowsiness or fatigue where the patient may fall asleep easily but can be roused to respond appropriately when stimulated. The patient shows decreased alertness but is still capable of engaging with stimuli.
C. Obtunded refers to a state where the patient has reduced alertness and responsiveness. They may respond slowly and require increased stimulation to achieve a response. They are less aware of their environment and have dulled senses.
D. Stupor is a state of near-unconsciousness where the patient can only be awakened by vigorous or painful stimuli. They may not respond to verbal commands but may show some response to more intense stimuli.
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