The nurse has placed her hands behind the client's head and flexed his neck forward as far as he can tolerate. During the test the client experiences leg pain and bends his knees. In addition, he complains of neck pain. This assessment finding is suggestive of what health problem?
Ischemic stroke
Trigeminal neuralgia
Meningitis
Bell's palsy
The Correct Answer is C
Choice A reason: Ischemic stroke causes focal deficits like weakness, not neck flexion-induced leg pain. This vascular event lacks meningeal irritation signs, misaligning with the positive Brudzinski’s sign of knee bending and neck pain in this assessment fully here.
Choice B reason: Trigeminal neuralgia triggers facial pain, not leg or neck pain with flexion. This cranial nerve V issue doesn’t involve meningeal inflammation, excluding it from the systemic response seen in this neck maneuver entirely and accurately here.
Choice C reason: Meningitis causes meningeal irritation; neck flexion (Brudzinski’s sign) elicits leg pain and knee bending. Neck pain aligns with inflammation, making this the likely diagnosis for the client’s response to this specific neurological test comprehensively here.
Choice D reason: Bell’s palsy affects cranial nerve VII, causing facial paralysis, not leg or neck pain. This peripheral nerve issue lacks the meningeal signs triggered by neck flexion, ruling it out as the cause in this scenario fully here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Ophthalmoscopy checks cranial nerve II (optic), not III, IV, or VI. It visualizes the retina, missing the eye movement control these nerves govern, making it irrelevant to their motor function assessment entirely here fully.
Choice B reason: The 6 cardinal fields test cranial nerves III (eye movement, pupil), IV (superior oblique), and VI (lateral rectus). This single technique evaluates all three by tracking coordinated eye motion, making it the most efficient method accurately here.
Choice C reason: Vibration on eyelids tests sensation, possibly cranial nerve V, not III, IV, or VI. These nerves control eye movement, not sensory input, excluding this from assessing their motor roles in this neurological exam fully here.
Choice D reason: Head turning with hand tracking involves neck muscles and possibly cranial nerve XI, not just III, IV, VI. This dilutes focus on eye-specific movements, making it less precise for these cranial nerves’ assessment entirely here.
Correct Answer is B
Explanation
Choice A reason: Small/moderate brown cerumen is normal, not a sign of infection, which shows pus or redness. Assessing further wastes effort, as cerumen protects the canal, and no symptoms like pain or hearing loss suggest pathology here requiring investigation.
Choice B reason: Documenting small/moderate brown cerumen as normal is correct, as it’s a protective earwax variant. Absent symptoms, this finding needs no intervention, aligning with standard practice to record typical ear assessments without escalating care unnecessarily in this case.
Choice C reason: Teaching hygiene isn’t needed for normal cerumen levels, which self-regulate. Excessive cleaning risks impaction or injury, and with no blockage or symptoms, this action overcomplicates a routine finding better left to natural ear processes here.
Choice D reason: Noting for ear drops assumes intervention for a non-issue. Normal brown cerumen doesn’t require softening or removal unless symptomatic, making this step premature and unnecessary, diverging from evidence-based care for typical ear findings fully.
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