If the client reports loss of short-term memory, the nurse would assess this using which one of the following?
Have the client repeat a series of three numbers, increasing to eight if possible.
Have the client describe his or her childhood illnesses.
Ask the client to describe how he or she arrived at this location.
Ask the client to count backward from 100 subtracting seven each time.
The Correct Answer is C
Short-term memory, which refers to the ability to retain and recall information recently acquired-typically within minutes. Short-term memory is often the first type affected in conditions such as delirium, dementia, or following brain injury.
Rationale for correct answer:
3. Ask the client to describe how he or she arrived at this location: Asking the client how they arrived (e.g., which route they took or who brought them) is an effective way to assess short-term memory, as it involves recalling recent events.
Rationale for incorrect answers:
1. Have the client repeat a series of three numbers, increasing to eight if possible: This test assesses attention span and immediate recall, not short-term memory. It is often used to evaluate concentration and the ability to retain and repeat information in the moment.
2. Have the client describe his or her childhood illnesses: This evaluates long-term (remote) memory, not short-term memory. Questions about childhood events, past jobs, or places lived help assess whether distant memories remain intact.
4. Ask the client to count backward from 100 subtracting seven each time: This is known as the serial sevens test, and it assesses concentration, attention, and executive function, not short-term memory.
Take home points
- Short-term memory is best evaluated by asking the client to recall recent events.
- Different cognitive functions are assessed with different techniques, so choosing the right method ensures accurate evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"E"},"D":{"answers":"D"},"E":{"answers":"A"}}
Explanation
The cranial nerves (CN I–XII) emerge directly from the brain and brainstem and control various motor, sensory, and parasympathetic functions of the head, neck, and some thoracic organs. During a comprehensive neurological assessment, the nurse must test these nerves to identify signs of neurologic dysfunction.
Rationale for correct answers:
1.XII Hypoglossal -e. Position of the tongue
The hypoglossal nerve controls the motor movement of the tongue. During assessment, the client is asked to stick out the tongue, and deviation or weakness indicates impairment of CN XII.
2. V Trigeminal -a. Motor innervation to the jaw
The trigeminal nerve has both motor and sensory components. Motor function includes muscles of mastication (chewing). The nurse assesses jaw movement and strength.
3. VI Abducens -b. Lateral movement of the eyeballs
The abducens nerve controls the lateral rectus muscle, which moves the eye laterally (abduction). Inability to look outward may suggest CN VI palsy.
4. IV Trochlear -d. Downward, inward eye movements
The trochlear nerve controls the superior oblique muscle, responsible for downward and inward eye movement. Difficulty with this motion may lead to vertical diplopia (double vision).
5. X Vagus -c. Sensation of the pharynx
The vagus nerve provides sensory innervation to the pharynx and larynx, and also has motor and parasympathetic functions. It plays a role in swallowing, speech, and the gag reflex.
Take home points
Each cranial nerve has specific motor, sensory, or both functions, and testing them individually helps identify the location and extent of neurological impairment.
- Cranial nerves IV (Trochlear), VI (Abducens), and III (Oculomotor) are especially important for eye movement coordination.
- CN V (Trigeminal) and XII (Hypoglossal) focus on facial sensation/mastication and tongue movement, respectively.
Correct Answer is C
Explanation
Lymph node palpation is a vital part of the head-to-toe physical exam, especially during head, neck, axillary, and inguinal assessments. It helps identify signs of infection, inflammation, or malignancy.
Rationale for correct answer:
3. Use the pads of two fingers in a circular motion: This is the recommended technique for palpating lymph nodes. The nurse uses the pads of the index and middle fingers, applying gentle pressure in a circular motion to detect superficial nodes.
Rationale for incorrect answers:
1. Use the flat of all four fingers in a vertical and then side-to-side motion: This technique is more appropriate for assessing the chest wall or abdominal structures, not for palpating lymph nodes.
2. Use the back of the hand and feel for temperature variation between the right and left sides: While the back of the hand (dorsal surface) is used to assess temperature, it is not used for palpating lymph nodes.
4. Compress the nodes between the index fingers of both hands: Compressing lymph nodes between fingers may not allow for an accurate assessment and could miss deeper nodes or fail to detect subtle changes in consistency.
Take home points
- The correct method to palpate lymph nodes is using the pads of two fingers in a circular motion, allowing for precise assessment of node size, texture, and mobility.
- Avoid using broad surfaces like the flat of the hand or non-sensitive areas like the back of the hand-these are not appropriate for lymph node evaluation.
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