The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following?

Answer and Explanation

The Correct Answer is D

A. 4+: This indicates very brisk reflexes with possible clonus, which is more than just brisk reflexes.

B. 2+: This indicates normal reflexes, not brisk.

C. 1+: This indicates diminished or hypoactive reflexes, not brisk.

D. 3+: This indicates brisk reflexes, which are faster than normal but without evidence of clonus.

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Correct Answer is B

Explanation

A. Tactile fremitus: This involves palpating vibrations on the chest wall as the patient speaks, not assessing chest expansion.

B. Chest expansion: This technique assesses the symmetrical movement of the chest during inhalation and exhalation, which is the correct assessment for this context.

C. Breath sounds: Breath sounds are assessed through auscultation rather than palpation.

D. Tissue consolidation: This involves detecting areas of increased density in lung tissue, often assessed through percussion or auscultation, not through the technique shown for chest expansion.

A. Head and face B. Mouth and throat C. Mental status examination D. Ears

Correct Answer is A

Explanation

A. Head and face: Cranial nerve VII (facial nerve) controls the muscles of facial expression, so its motor function is assessed by examining the movement of the face, such as smiling, frowning, or raising eyebrows.

B. Mouth and throat: While cranial nerve VII does innervate some muscles involved in facial expressions that might affect the mouth, a more comprehensive assessment of its motor function occurs in the head and face region.

C. Mental status examination: This assesses cognitive functions rather than specific motor functions of cranial nerves.

D. Ears: The assessment of cranial nerve VII does not typically involve the ears.

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The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following?

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Naxlex Comprehensive Predictor Exams

The nurse is performing the technique shown. What is the nurse assessing?

Correct Answer is B

Explanation

When performing a head-to-toe assessment, during which part would the nurse assess the motor function of cranial nerve VII?

Correct Answer is A

Explanation

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