The nurse is taking the health history of a 78-year-old man. During the history, his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." In doing the assessment of his sensory system, the nurse would do which of the following?
Before testing, the nurse would assess the patient's mental status and ability to follow directions at this time.
The nurse would perform the tests, knowing that mental status does not affect sensory ability.
The nurse would not do this part of the examination because results would not be valid.
The nurse would proceed with the explanations of each test, making sure the wife understands.
The Correct Answer is A
A. Before testing, the nurse would assess the patient's mental status and ability to follow directions at this time: Sensory testing requires the patient to understand instructions and respond appropriately. Assessing cognitive status first ensures that any abnormal findings are not due to confusion or inability to follow directions.
B. The nurse would perform the tests, knowing that mental status does not affect sensory ability: Mental status directly affects the accuracy of sensory assessment. If the patient cannot comprehend instructions, the results may be unreliable, making this approach inappropriate.
C. The nurse would not do this part of the examination because results would not be valid: While cognitive impairment may complicate sensory testing, the nurse can still attempt assessment after evaluating the patient’s mental status, using simplified instructions or assistance as needed.
D. The nurse would proceed with the explanations of each test, making sure the wife understands: The patient, not the caregiver, must perform and respond to sensory testing. Explaining the test only to the wife does not ensure accurate assessment of the patient’s sensory function.
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Related Questions
Correct Answer is D
Explanation
A. distal to proximal: Assessing from distal to proximal does not follow the recommended approach because it may miss important findings in the larger joints that influence distal movement. Proximal structures should be assessed first since they provide stability and strength to distal areas.
B. posterior to anterior: Moving from posterior to anterior is not the standard sequence for musculoskeletal assessment. The goal is to assess systematically, focusing on overall function and progression rather than body surface orientation.
C. anterior to posterior: Similar to posterior-to-anterior, this sequence does not align with musculoskeletal assessment standards. Changing orientation does not provide a structured approach to identifying joint or muscle abnormalities.
D. proximal to distal: The correct method is to examine joints and muscles from proximal to distal. This approach ensures evaluation of the larger, supporting joints first, which helps in understanding how proximal function influences distal performance and detecting abnormalities in a logical sequence.
Correct Answer is C
Explanation
A. Motor component of CN X and sensory component of CN VII: CN X (vagus) controls muscles of the pharynx and larynx, and CN VII (facial) has both motor and sensory components. However, loss of facial movement and absence of blink specifically indicate a problem with the motor function of CN VII rather than CN X.
B. Motor and sensory component of CN XI: CN XI (accessory nerve) controls the sternocleidomastoid and trapezius muscles. Dysfunction would present as difficulty with shoulder shrug or head rotation, not facial movement or blinking.
C. Motor component of CN VII: CN VII (facial nerve) controls muscles of facial expression, including blinking and movement of facial features. The findings of absent blink, intact sensation, and facial muscle weakness on one side indicate a motor deficit of CN VII.
D. Motor component of CN IV: CN IV (trochlear nerve) controls the superior oblique muscle of the eye. Dysfunction would affect eye movement, specifically downward and inward gaze, rather than facial expression or blink reflex.
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