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 B

Explanation

A. The obturator sign is used to assess for appendicitis, not meningitis. To perform this test, the patient’s right knee is flexed to 90 degrees, and the nurse rotates the hip internally and externally. Pain during this maneuver can indicate irritation of the obturator muscle, which is associated with inflammation of the appendix.

B. The Brudzinski sign is a clinical test used to assess meningeal irritation. When the patient’s neck is passively flexed while lying supine, a positive Brudzinski sign is indicated if the patient involuntarily flexes their knees and hips in response to neck pain. This sign is often seen in meningitis as a result of irritation of the meninges.
C. The Phalen sign is used to diagnose carpal tunnel syndrome. The patient flexes their wrists and holds the position for a period of time to see if symptoms of numbness or tingling appear in the fingers, which would indicate median nerve compression at the wrist. This sign is unrelated to meningitis.
D. The Tinel sign is also used to diagnose carpal tunnel syndrome and other peripheral nerve issues. It involves tapping on the nerve (such as the median nerve at the wrist) to see if it causes tingling or a “pins and needles” sensation along the nerve’s distribution. Like the Phalen sign, it is not related to meningitis.

A. Concentration B. Attention C. Affect D. Abstract reasoning

Correct Answer is D

Explanation

A. Concentration refers to the ability to focus on a specific task or thought for a period of time. While concentration is important for cognitive functioning, it is not the specific skill being assessed when interpreting the meaning of a proverb.
B. Attention is the ability to focus and direct mental resources towards a specific task or stimulus. While attention is necessary for understanding and processing information, the task of interpreting a proverb is more related to higher-level cognitive processes rather than just the ability to maintain focus.
C. Affect refers to the emotional state or mood of a person. It involves how emotions are expressed and experienced. Assessing affect involves observing the client’s emotional responses, not their ability to interpret abstract concepts. Therefore, affect is not the focus of this assessment.
D. Abstract reasoning is the ability to understand and interpret concepts and ideas that are not directly observable or tangible. It involves thinking beyond concrete facts to understand underlying meanings, patterns, and relationships. Interpreting a proverb, which involves understanding a figurative meaning rather than a literal one, is a test of abstract reasoning. The ability to grasp the deeper meaning behind “A penny saved is a penny earned” reflects the client's capacity for abstract reasoning.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is diagnosed with Meningitis. During the physical examination in the supine position, the nurse flexed the patient's neck and the patient flexed his knees and hip while complaining of neck pain. This is known as:

Correct Answer is B

Explanation

During an assessment, the nurse asks a client to explain what the following means: "A penny saved is a penny earned." The nurse is assessing which of the following?

Correct Answer is D

Explanation

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