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 A

Explanation

Rationale:
A. An audible abdominal bruit: An abdominal bruit may indicate turbulent blood flow, often due to an abdominal aortic aneurysm (AAA). Given the client’s report of deep, constant abdominal pain radiating to the back—classic signs of a possible AAA—this finding is critical and must be reported immediately to prevent life-threatening rupture.

B. Hypoactive bowel sounds in all quadrants: Hypoactive bowel sounds suggest slowed intestinal activity, possibly related to pain, ileus, or peritonitis. Although concerning, it is not as immediately life-threatening as a possible vascular emergency indicated by the presence of an abdominal bruit.

C. A bulge over umbilicus when coughing: A bulge during coughing suggests a possible umbilical hernia. While hernias can become serious if strangulated, they typically do not present with constant radiating pain to the back, making this finding less urgent compared to the suspicion of a vascular emergency.

D. Intermittent pain on deep inspiration: Intermittent pain on deep inspiration could suggest pleuritic pain or musculoskeletal issues rather than a primary abdominal pathology causing constant, radiating pain. While it should be documented and further evaluated if persistent, it is less likely to be the most critical finding in a client presenting with severe abdominal pain radiating to the back.

Correct Answer is []

Explanation

Rationale:

• Lobar pneumonia: Lobar pneumonia involves infection and consolidation of one or more lobes of the lung, leading to dullness on percussion, decreased breath sounds, increased respiratory effort, and localized chest expansion asymmetry. This matches the client's decreased right lung sounds, dullness, and accessory muscle use.

• Acute bronchitis: Acute bronchitis is an infection of the bronchi causing cough and sometimes wheezing, but it typically does not cause focal decreased breath sounds, dullness on percussion, or asymmetrical chest expansion. Therefore, it is less likely based on the clinical findings.

• Pleural effusion: Pleural effusion results in fluid collection in the pleural space, leading to decreased breath sounds and dullness on percussion. However, pleural effusion typically presents with more significant respiratory compromise and often no cough, making it slightly less fitting than lobar pneumonia.

• Atelectasis: Atelectasis causes collapse of alveoli, leading to decreased breath sounds and dullness, similar to pneumonia. However, it usually follows surgery, immobilization, or obstruction rather than an acute infectious presentation with fever and cough like this case suggests.

• Auscultate the lungs for adventitious breath sounds: Because the client already has decreased breath sounds in the right lower lobe, auscultating for additional sounds like crackles or bronchial breathing is important. These adventitious sounds would support the suspicion of lobar pneumonia progression.

• Assess for tactile fremitus: Assessing for increased tactile fremitus would help confirm consolidation in the right lung base. Since the client already shows signs of consolidation, tactile fremitus could provide additional evidence but is less critical than monitoring breathing effort and lung sounds.

• Assess for prolonged expiration: The client’s main problem is decreased air movement and dullness, not wheezing or air trapping. Prolonged expiration is usually associated with obstructive diseases like asthma, which does not match this client's current symptoms or findings.

• Assess for muffled heart sounds: There is no indication of pericardial problems like tamponade in the client’s symptoms. The presence of decreased lung sounds and dullness point toward a lung issue, not a cardiac one, so assessing heart sounds for muffling is unnecessary here.

• Inspect the chest for asymmetrical expansion: Chest expansion is already decreased on the right side, and further inspection for asymmetry will help monitor if the consolidation worsens. Watching chest movement will guide decisions about respiratory support needs.

• Respiratory rate and pulse: The client’s respiratory rate is elevated at 24 breaths per minute, and continued monitoring is necessary to catch signs of respiratory fatigue or worsening infection. Heart rate monitoring is also important because tachycardia may develop if hypoxia or sepsis worsens.

• Crackles: While crackles may be heard in pneumonia, they are not currently reported in this client’s lung exam. Instead of focusing on finding crackles, priority is on monitoring the client’s breathing work, oxygenation, and overall respiratory status.

• Cyanosis: The client's oxygen saturation is 94% on room air, but cyanosis would indicate worsening oxygenation if it develops. Observing for cyanosis is crucial because pneumonia can quickly lead to hypoxia despite initially normal oxygen levels.

• Wheezing: Wheezing suggests airway narrowing, but this client’s symptoms point more to alveolar consolidation without signs of bronchospasm. Wheezing is not expected in lobar pneumonia and should not be the main focus of respiratory assessment.

• Loud bronchial breathing: Loud bronchial breath sounds over the right lower lobe would confirm consolidation but are already supported by dullness and decreased lung sounds. Monitoring clinical signs like breathing effort and oxygenation is more important for this client’s ongoing evaluation.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse examines a client admitted with a deep, constant pain in the abdomen that radiates to the back. Which finding is most important for the nurse to report to the healthcare provider (HCP)?

Correct Answer is A

Explanation

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

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