How should the nurse evaluate the client's motor ability and function?
Inspect muscle symmetry in the upper and lower extremities
The RN asks the client to squeeze their hand or show 2 fingers and lift their arm of the bed
Check plantar response and deep tendon-reflex testing bilaterally
Comparative cranial nerve assessments and ability to follow simple commands
The Correct Answer is B
A. Inspect muscle symmetry in the upper and lower extremities
While muscle symmetry is important, it only assesses muscle mass and atrophy, not motor function or coordination.
B. The RN asks the client to squeeze their hand or show 2 fingers and lift their arm off the bed
This assesses motor strength and coordination, which are key components of motor ability. Handgrip strength and upper limb movement provide important information about neurological function.
C. Check plantar response and deep tendon reflex testing bilaterally
These tests assess reflexes and neurological pathways rather than motor function and coordination.
D. Comparative cranial nerve assessments and ability to follow simple commands
While following commands assesses cognition, it does not directly evaluate muscle strength or motor ability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Wearing sunglasses while symptomatic
Sunglasses reduce photophobia, but they do not prevent corneal damage from dryness.
B. Applying an eye patch before sleep
Bell's palsy affects cranial nerve VII (facial nerve), leading to incomplete eye closure. This can cause corneal abrasions and dryness. An eye patch at night prevents corneal injury.
C. An antihistamine eye drop
Antihistamine eye drops may dry out the eye further, worsening the risk of corneal injury.
D. Antibiotic ophthalmic ointment
Antibiotics are not necessary unless an infection is present. Lubricating drops or artificial tears are more appropriate.
Correct Answer is B
Explanation
A. Vocalization, strength, and pupillary response and accommodation are not components of GCS. Strength testing is part of a motor exam, and pupillary response is part of a cranial nerve assessment.
B. Eye opening, verbal response, and motor response are the three components of the Glasgow Coma Scale (GCS), which assesses a client’s neurological status and level of consciousness.
C. Pupillary reaction, eye opening, and motor response is incorrect because pupillary reaction is not a component of the GCS.
D. Motor response, sensory response, and level of consciousness is incorrect because sensory response is not a part of the GCS.
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