When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:

Positive Romberg sign.

Ataxia.

Lack of coordination.

Negative Homans sign.

Answer and Explanation

The Correct Answer is A

A.   A positive Romberg test occurs when a person loses balance or sways when standing with their eyes closed, indicating a problem with proprioception or balance.
B.   Ataxia refers to a lack of coordination or motor control, but the Romberg sign specifically tests balance and proprioception, which is different from ataxia.
C.   Lack of coordination may be part of ataxia or other neurological issues, but the Romberg sign specifically refers to balance issues when eyes are closed.
D.   The Homans sign is used to test for deep vein thrombosis (DVT) and is not relevant to the test for balance and proprioception described in the scenario.

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Correct Answer is B

Explanation

A. Muscle atrophy, which typically occurs in older adults, may actually reduce BMI, not increase it, because muscle mass decreases with age.
B. Height may decrease due to changes in bone density. As people age, bone density decreases, and the vertebrae can compress, leading to a loss in height. This is a common occurrence in older adults.
C. Increased skin elasticity will affect the waist-hip ratio. Skin elasticity does not directly affect the waistto-hip ratio. The waist-to-hip ratio is more related to fat distribution than to skin elasticity.
D. Increased muscle mass will affect the mid-arm circumference measurements. Older adults typically experience muscle loss, not an increase in muscle mass, so this statement would not be accurate for an elderly client.

A. Motor component of CN IV B. Motor component of CN VI C. Motor and sensory components of CNX D. Motor component of CN VII

Correct Answer is D

Explanation

A. The trochlear nerve controls the superior oblique muscle of the eye and is not related to facial movements.
B. The abducens nerve controls the lateral rectus muscle of the eye, responsible for eye movement, not facial muscles.
C. The vagus nerve affects the soft palate, pharynx, and larynx, but does not contribute to facial expression.
D. Asymmetry in facial movements, like smiling, frowning, and puffing the cheeks, suggests dysfunction of the facial nerve (CN VII).

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When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:

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Naxlex Comprehensive Predictor Exams

A nurse needs to obtain anthropometric measures of an 80-year-old client. Which of the following statements is true regarding this situation?

Correct Answer is B

Explanation

During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs?

Correct Answer is D

Explanation

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