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The nurse is assessing a patient in the acute hospital setting that has had a diagnosis of right-sided stroke. The nurse completes a comprehensive neurological assessment including assessing the client for graphesthesia. What are the actions the nurse would take to perform this assessment appropriately?

The client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object.

The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred.

The nurse will ask the client to close his eyes, and will ask that he identify a familiar object placed in the client’s hand.

The client is asked to identify the number of points felt when the nurse touches the client with the ends of two applicators at the same time.

Answer and Explanation

The Correct Answer is A

Choice A reason: Graphesthesia tests cortical sensory function by tracing numbers on the palm with eyes closed. A right-sided stroke may impair this on the left side, making this the correct method to assess parietal lobe processing accurately here.
Choice B reason: Simultaneous bilateral touch tests extinction, not graphesthesia. This assesses neglect, not the ability to interpret shapes, missing the specific sensory integration focus needed for graphesthesia in this stroke assessment entirely and fully here.
Choice C reason: Identifying objects with eyes closed tests stereognosis, not graphesthesia. This evaluates tactile recognition, not number tracing, diverging from the precise cortical sensory skill targeted in this neurological exam for stroke effects here.
Choice D reason: Two-point discrimination tests sensory acuity, not graphesthesia. This measures point differentiation, not shape recognition, making it unrelated to assessing the parietal lobe’s interpretive ability post-stroke as intended in this scenario fully.

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Correct Answer is C

Explanation

Choice A reason: Heel-to-shin tests cerebellar coordination, not balance like Romberg’s. It assesses motor precision, not proprioception or vestibular function, which Romberg’s targets by checking sway with eyes closed, making this technique irrelevant to the intended assessment here.

Choice B reason: Walking on heels and toes evaluates motor strength and coordination, not stationary balance. Romberg’s tests proprioceptive stability, not gait, missing the core focus on vestibular and sensory integration critical to this neurological balance assessment fully.

Choice C reason: Romberg’s test assesses balance by having the client stand, feet together, eyes open then closed for 20 seconds. Sway with eyes closed indicates proprioceptive or vestibular issues, making this the precise, standard technique for this evaluation accurately.

Choice D reason: Finger-to-thumb tests fine motor skills and coordination, not balance. Romberg’s focuses on postural stability via sensory input, not hand dexterity, rendering this action unrelated to assessing the client’s equilibrium as intended in this context completely.

A. Macular degeneration B. Recent eye trauma C. Bilateral cataracts D. Narcotic use

Correct Answer is D

Explanation

Choice A reason: Macular degeneration impairs central vision, not pupil size. Pinpoint pupils and lethargy suggest systemic effects, not retinal aging, making this unrelated to the neurological and ocular findings in this emergency setting entirely and fully here.
Choice B reason: Eye trauma may dilate pupils from injury, not pinpoint them. Lethargy and change per the significant other point to systemic causes, not local trauma, excluding this as the likely explanation for this presentation comprehensively here.
Choice C reason: Bilateral cataracts cloud lenses, not affecting pupil size or alertness. Pinpoint pupils with lethargy suggest a neurological cause, not lens opacity, rendering this irrelevant to the acute change observed in this client fully here.
Choice D reason: Narcotic use, like opioids, causes pinpoint pupils via cranial nerve III stimulation and lethargy from CNS depression. This matches the sudden change and symptoms, making it the most likely interpretation in this emergency case accurately here.

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Naxlex Comprehensive Predictor Exams

A nurse is completing the Romberg's test on a patient. Which is the correct technique for conducting this?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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