The nurse is taking a health history from a client. The client tells the nurse that. "It feels like the room is spinning." How should the nurse document this finding?

Vertigo

Seizure activity

Dizziness

Syncope

Answer and Explanation

The Correct Answer is A

A.   Vertigo is the sensation of spinning or movement when stationary and is often associated with inner ear problems.
B.   Seizure activity involves abnormal electrical activity in the brain and might present with various symptoms but not necessarily the feeling of spinning.
C.   Dizziness is a more general term that can include feelings of light-headedness or unsteadiness without a specific spinning sensation.
D.   Syncope refers to fainting or loss of consciousness due to decreased blood flow to the brain, not the sensation of spinning.

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Correct Answer is C

Explanation

A. Plantarflexion and dorsiflexion refer to movements of the foot and are unrelated to the Phalen test.
B. Hyperextension of the wrists with the palmar surfaces touching is not the correct maneuver for the Phalen test.
C. The Phalen test involves holding both hands back to back while flexing the wrists at a 90- degree angle for about 60 seconds, which may induce symptoms of carpal tunnel syndrome in those affected.
D. Hyperextending the wrists with the palms together doesn’t simulate the stress on the median nerve in the same way as the Phalen test.

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 taking a health history from a client. The client tells the nurse that. "It feels like the room is spinning." How should the nurse document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse suspects that a client has carpal tunnel syndrome and prepares to conduct the Phalen test. What instructions should the nurse give the client to perform the Phalen test?

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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