The nurse notices the client's physical appearance, behavior, mobility, and neurological status when they enter the room.
Which of the following is the nurse assessing?

General survey.

Medical history.

Biographical data.

Social history.

Answer and Explanation

The Correct Answer is A

Choice A rationale

The general survey is an overall assessment of a client's physical appearance, behavior, mobility, and neurological status. It provides a comprehensive overview of the client's health and well-being, making it the focus of the nurse's observations in this scenario.

Choice B rationale

Medical history includes past and current health conditions, surgeries, medications, and family health history. While important, it is not the focus of the nurse's immediate observations in this scenario.

Choice C rationale

Biographical data involves personal information such as age, gender, occupation, and marital status. While relevant to the client's health, it is not the primary focus of the nurse's observations in this scenario.

Choice D rationale

Social history includes information about the client's lifestyle, habits, and social environment. While valuable for understanding the client's overall health context, it is not the focus of the nurse's immediate observations in this scenario. .

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Correct Answer is A

Explanation

Choice A rationale

The sides of the mouth being symmetric when the patient smiles indicate intact function of the facial cranial nerve (CN VII). This nerve controls the muscles responsible for facial expressions, including smiling, frowning, and closing the eyes. Symmetry in these actions suggests that the facial nerve is functioning properly and that there is no nerve damage or weakness.

Choice B rationale

The patient's eyes moving to the left, right, up, down, and obliquely during conversation are functions of the oculomotor nerve (CN III), trochlear nerve (CN IV), and abducens nerve (CN VI), not the facial cranial nerve (CN VII). These nerves work together to control the movements of the eye muscles, enabling the eyes to move in different directions and maintain proper alignment.

Choice C rationale

Periodic blinking of the eyelids involves the oculomotor nerve (CN III) and the facial nerve (CN VII). The oculomotor nerve controls the muscles that lift the eyelid, while the facial nerve controls the muscles that close the eyelid. Blinking is a coordinated action involving both nerves, but the observation alone is not sufficient to determine the integrity of CN VII.

Choice D rationale

The patient moistening the lips with the tongue involves the function of the hypoglossal nerve (CN XII), which controls the movements of the tongue. The hypoglossal nerve is responsible for the motor control of most of the tongue muscles, allowing for actions like licking the lips, speaking, and swallowing. It is not related to the facial cranial nerve (CN VII).

A. The nurse will understand the unaffected ear will show lateralization to the Weber's test. B. Place the activated tuning fork to the mid skull and ask if the patient can hear it louder in either ear. C. Place the activated tuning fork to the patient's mastoid bone first then place over air. D. Place the activated tuning fork to the client's ear over the mastoid bone then activate it again over the air.

Correct Answer is B

Explanation

Choice A rationale

Lateralization to the unaffected ear in Weber's test actually indicates sensorineural hearing loss in the affected ear. This choice is incorrect as it doesn’t describe the correct procedure for the test.

Choice B rationale

The Weber's test involves placing an activated tuning fork in the midline of the skull and asking the patient if the sound is heard more loudly in either ear. This helps determine if there is lateralization, which is key in diagnosing the type of hearing loss. Thus, this is the correct procedure for the test.

Choice C rationale

Placing the tuning fork on the mastoid bone and then over air is actually part of the Rinne test, not the Weber test. This choice is, therefore, incorrect for the Weber test.

Choice D rationale

Similar to Choice C, this process describes the Rinne test, which compares air conduction and bone conduction of sound. This is not the correct method for performing Weber’s test.

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The nurse notices the client's physical appearance, behavior, mobility, and neurological status when they enter the room.Which of the following is the nurse assessing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While taking a history, the nurse observes that the patient's facial cranial nerves (CN VII) are intact based on which behaviors of the patient?

Correct Answer is A

Explanation

The nurse plans to assess the client's hearing.What action should the nurse take when performing the Weber's test?

Correct Answer is B

Explanation

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The nurse notices the client's physical appearance, behavior, mobility, and neurological status when they enter the room.
Which of the following is the nurse assessing?