The nurse is preparing to screen a client for deep vein thrombosis (DVT). Which of the following techniques should the nurse recognize as the appropriate technique to screen for DVT?

measure the circumference of the ankle.

measure the calf at the widest point with a tape measure.

check the dorsalis pedis pulse with the palm of the hand.

compress the dorsalis pedis pulse, looking for blood return.

Answer and Explanation

The Correct Answer is B

A.   Measuring the circumference of the ankle is not a specific method for screening DVT.
B.   Assessing the calf at its widest point with a tape measure can reveal differences in calf size, which might indicate swelling due to a DVT.
C.   Checking the dorsalis pedis pulse assesses peripheral circulation but doesn't specifically screen for DVT.
D.   Compressing the dorsalis pedis pulse to check for blood return is part of assessing peripheral circulation but doesn’t directly screen for DVT.

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Correct Answer is C

Explanation

A. The condyle of the mandible is the rounded protuberance at the end of the mandible bone but doesn't refer to the joint.
B. The zygomatic arch of the temporal bone is part of the skull structure and not directly associated with the mandibular joint.
C. The temporomandibular joint (TMJ) is the joint where the mandible articulates with the temporal bone of the skull, allowing for jaw movement and chewing.
D. The intervertebral foramen is a space between vertebrae through which spinal nerves exit the spinal cord.

A. When the client sticks out the tongue it is in the midline and without tremors or deviation. B. Client follows an object with eyes without nystagmus or strabismus. C. Client demonstrates the ability to hear normal conversation. D. Client moves the head and shoulders against resistance with equal strength.

Correct Answer is D

Explanation

A. Cranial Nerve XI (Accessory nerve) is not involved in tongue movement; it controls muscles involved in head and shoulder movement.
B. Eye movement and control relate more to Cranial Nerves III, IV, and VI, which control eye muscles.
C. Hearing is primarily assessed by Cranial Nerve VIII (Vestibulocochlear nerve).
D. Cranial Nerve XI innervates the sternocleidomastoid and trapezius muscles, enabling movements like head turning and shoulder shrugging against resistance.

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The nurse is preparing to screen a client for deep vein thrombosis (DVT). Which of the following techniques should the nurse recognize as the appropriate technique to screen for DVT?

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Naxlex Comprehensive Predictor Exams

The nurse is performing a physical assessment of the client's mandible and temporal bone. The nurse recognizes that the articulation of the mandible and the temporal bone is called?

Correct Answer is C

Explanation

The nurse tests the function of Cranial Nerve XI while performing a physical examination on a client. Which statement best describes the response the nurse should expect if Cranial Nerve XI is intact?

Correct Answer is D

Explanation

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