The nurse is performing a cranial nerve exam on an older adult client. The nurse notes that the client has a reduced upward gaze, a decreased corneal reflex, a high frequency hearing loss, and a reduced gag reflex. Which action should the nurse take next?

Review past history for any episodes of a cerebral cortex lesion.

Continue the assessment of the next pairs of cranial nerves.

Assess the spinal reflexes for demyelination symptoms.

Implement neurological (neuro) vital signs every 2 hours to detect Cushing's triad.

Answer and Explanation

The Correct Answer is B

Rationale:
A. Review past history for any episodes of a cerebral cortex lesion: While a history of cerebral cortex lesions may explain some neurologic deficits, the findings described are consistent with normal age-related changes. Immediately jumping to investigate for cortical damage is unnecessary without stronger evidence of acute or severe dysfunction.

B. Continue the assessment of the next pairs of cranial nerves: Mild reductions in upward gaze, corneal reflex, gag reflex, and high-frequency hearing are common and expected in older adults due to aging of the neurological and sensory systems. The nurse should proceed systematically with the full cranial nerve examination to complete the assessment.

C. Assess the spinal reflexes for demyelination symptoms: Demyelination disorders like multiple sclerosis are rare in older adults without specific symptoms suggesting motor or sensory loss beyond what has been described. The findings here do not immediately suggest demyelination, so spinal reflex testing is not the next priority.

D. Implement neurological (neuro) vital signs every 2 hours to detect Cushing's triad: Cushing's triad indicates serious increased intracranial pressure and includes hypertension, bradycardia, and irregular respirations. The client's described findings do not suggest acute neurological deterioration requiring intensive neurovital monitoring.

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Correct Answer is D

Explanation

Rationale:
A. Rapid strep test: A rapid strep test screens for streptococcal throat infections and is unrelated to urinary symptoms. It would not help identify the cause of painful urination in a client with diabetes mellitus.

B. Nitazine pH strip: Nitazine pH testing is primarily used to assess amniotic fluid leakage in pregnant women, not for urinary tract infections (UTIs). It would not provide helpful information for evaluating dysuria in this situation.

C. Finger stick glucose: While important for monitoring diabetes management, finger stick glucose does not directly address the acute complaint of painful urination. It would not diagnose a urinary tract infection, which is the immediate concern.

D. Urine dipstick test: A urine dipstick test screens for leukocytes, nitrites, blood, and glucose in the urine and is the appropriate first screening for suspected UTI. Clients with uncontrolled diabetes are at higher risk for UTIs, and the dipstick can quickly detect infection-related changes.

A. Evaluate ability to brush and floss teeth. B. Ask client to describe reactions in a difficult situation. C. Observe physical grooming and hygiene. D. Tell the client to repeat a phrase that was said earlier.

Correct Answer is D

Explanation

Rationale:
A. Evaluate ability to brush and floss teeth: Assessing the ability to perform personal hygiene activities evaluates functional status and motor skills, not specifically cognitive ability. It reflects activities of daily living (ADLs) rather than direct cognitive processing.

B. Ask client to describe reactions in a difficult situation: Asking about reactions assesses judgment and emotional response but not cognitive functions like memory, attention, or orientation, which are the primary focus in a cognitive ability exam.

C. Observe physical grooming and hygiene: Observing grooming and hygiene helps assess self-care and possibly hints at cognitive decline if hygiene is poor, but by itself, it does not directly measure specific cognitive abilities such as memory or recall.

D. Tell the client to repeat a phrase that was said earlier: Asking the client to recall and repeat a previously stated phrase directly assesses short-term memory, an important component of cognitive ability. This action is a standard part of evaluating memory retention and cognitive functioning.

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The nurse is performing a cranial nerve exam on an older adult client. The nurse notes that the client has a reduced upward gaze, a decreased corneal reflex, a high frequency hearing loss, and a reduced gag reflex. Which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is completing an assessment for a client with uncontrolled diabetes mellitus (DM) who came to the clinic reporting frequent, painful urination. Which screening test should the nurse perform first?

Correct Answer is D

Explanation

Which assessment action should the nurse use when performing a cognitive ability exam?

Correct Answer is D

Explanation

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