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

Answer and Explanation

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.

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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.

A. Prepare for immediate abdominal surgery B. Determine if there are any allergies to food or drugs C. Administer antibiotics as ordered after culture results are available D. Obtain a urine specimen

Correct Answer is D

Explanation

A. Prepare for immediate abdominal surgery
There is no indication of active hemorrhage or peritonitis at this point. Further assessment is needed before deciding on surgery.

B. Determine if there are any allergies to food or drugs
Allergy history is important, but it is not the immediate priority for this client.

C. Administer antibiotics as ordered after culture results are available
Antibiotics may be needed if infection is suspected, but the priority is assessing kidney function due to the risk of rhabdomyolysis from muscle breakdown.

D. Obtain a urine specimen
Flank pain after a crush injury suggests possible rhabdomyolysis or kidney damage. The urine should be tested for myoglobinuria (tea-colored urine), hematuria, or kidney injury markers.

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How should the nurse evaluate the client's motor ability and function?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Due to cranial nerve involvement in Bell's palsy, which of the following would prevent a potential complication from the disorder?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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