When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding?

Stationary soft palate on phonation

Uvula and soft palate rising bilaterally

Asymmetrical soft palate

Deviation of uvula when client says "ah"

Answer and Explanation

The Correct Answer is B

A.   The soft palate should move during phonation. If it remains stationary, it could indicate a problem with cranial nerves IX and X. These nerves control the movement of the soft palate and the muscles involved in phonation.
B.   This is the normal finding. During the assessment, when the patient says "ah," the uvula and soft palate should rise symmetrically. This movement indicates that cranial nerves IX and X are functioning properly. If the uvula and soft palate rise bilaterally, it means that both sides of the soft palate are being controlled correctly by these nerves.
C.   Asymmetry in the soft palate could indicate dysfunction of cranial nerves IX and X. Normally, the soft palate should rise evenly on both sides when the patient says "ah." An asymmetrical soft palate suggests that one side is not functioning correctly, which may be due to nerve damage or weakness.
D.   This is not a normal finding. If the uvula deviates to one side when the patient says "ah," it indicates a problem with the function of the cranial nerves. The deviation is usually towards the side opposite to the weak or affected side. This asymmetry in uvula movement can be due to a weakness or paralysis of the muscles on one side controlled by these nerves.

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Correct Answer is A

Explanation

A. Flight of ideas is characterized by a rapid and continuous flow of thoughts where the individual frequently shifts topics, often making it difficult to follow their conversation. This is commonly observed in conditions like mania or hypomania, often seen in bipolar disorder.
B. Confabulation involves fabricating or inventing stories or information to fill in gaps in memory. It is often seen in conditions affecting memory or cognition, such as Korsakoff’s syndrome or certain types of dementia.
C. Depression typically involves symptoms such as low mood, decreased energy, and lack of interest in activities, rather than rapid speech or topic shifts. The client’s accelerated pace of speech and jumping from topic to topic do not align with the characteristics of depression.
D. Schizophrenia is a broad term for a range of symptoms, including hallucinations, delusions, disorganized thinking, and impaired social functioning. While disorganized thinking can be a symptom of schizophrenia, the specific behavior described (accelerated speech and jumping topics) more specifically indicates flight of ideas, which is not exclusive to schizophrenia.

A. Check for a Babinski reflex B. Position the client prone C. Ensure no injury to the cervical spine D. Check for evidence of fever and chills

Correct Answer is C

Explanation

A. The Babinski reflex is a test used to assess the integrity of the corticospinal tract and is particularly useful in evaluating neurological function in infants and adults with neurological conditions. However, it is not specifically related to testing for meningeal irritation.
B. Positioning the client prone (lying on their stomach) is not typically used when testing for meningeal irritation. The tests for meningeal irritation, such as the Brudzinski sign and Kernig sign, are performed with the client in a supine (lying on their back) position to accurately assess reactions to neck flexion and leg movements.
C. Before performing tests for meningeal irritation, such as neck flexion, it is important to ensure that the client does not have an injury to the cervical spine. If there is a possibility of cervical spine injury, performing neck flexion could exacerbate the injury. Ensuring that there is no cervical spine injury helps to avoid causing harm and ensures a safe examination.
D. While fever and chills can be associated with infections that may cause meningeal irritation (such as meningitis), checking for these symptoms is not the first step in assessing meningeal irritation itself.

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When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is C

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