Which of the following statements would be the most appropriate to include in the medical record?
The left side of the mouth is noted to be drooping. Speech is slurred but is understandable with appropriate word choices.
The client is having a stroke.
Mouth is asymmetrical, and I am having trouble understanding what he is saying.
The client is having trouble speaking probably due to his drooping mouth.
The Correct Answer is A
Choice A reason: This statement is objective, describing observable clinical findings such as facial drooping and slurred but understandable speech with appropriate word choices. It avoids speculative diagnoses, adhering to medical documentation standards that prioritize factual, measurable data. Neurological assessments often note such symptoms, which may indicate conditions like stroke or Bell’s palsy, but the statement remains descriptive, allowing for accurate clinical interpretation.
Choice B reason: Stating “the client is having a stroke” is a definitive diagnosis, which is inappropriate for a medical record without confirmatory diagnostic tests like a CT scan or MRI. Stroke involves cerebral ischemia or hemorrhage, causing symptoms like facial droop, but documentation must avoid premature conclusions to prevent misdiagnosis and ensure proper clinical evaluation.
Choice C reason: This statement is subjective, focusing on the observer’s difficulty understanding speech and using vague terms like “asymmetrical.” It lacks specificity about speech clarity or word choice, which are critical in neurological assessments. Objective documentation should quantify symptoms, such as degree of asymmetry or speech intelligibility, to support accurate medical decision-making.
Choice D reason: This statement speculates a causal link between drooping mouth and speech difficulty without evidence, using “probably,” which is inappropriate for medical records. It lacks detail on speech quality or other neurological signs. Accurate documentation requires precise, objective observations to guide diagnosis, such as noting specific symptoms without assuming unconfirmed etiologies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Facial droop is an unexpected neurological finding, often indicating cranial nerve VII (facial nerve) dysfunction, as seen in stroke or Bell’s palsy. It disrupts symmetrical muscle movement, signaling potential brain or nerve pathology. This abnormality requires urgent evaluation to determine underlying causes like ischemia or inflammation.
Choice B reason: Swallowing without coughing is a normal finding, reflecting intact cranial nerves IX and X. Dysphagia or coughing during swallowing would suggest neurological impairment, but this choice indicates expected function, making it a typical result in a neurological assessment of swallowing capability.
Choice C reason: Spontaneous eye opening is a normal finding, indicating intact brainstem and cranial nerve function, particularly cranial nerve III. It is expected in conscious patients and does not suggest neurological dysfunction, unlike failure to open eyes, which could indicate coma or severe impairment.
Choice D reason: Understandable speech is a normal finding, reflecting coordinated function of cranial nerves and brain regions like Broca’s area. Slurred or incoherent speech would be abnormal, but this choice indicates expected neurological performance, not an unexpected outcome in a standard assessment.
Correct Answer is D
Explanation
Choice A reason: Swallowing water tests cranial nerves IX and X, not XI (spinal accessory), which controls trapezius and sternocleidomastoid muscles. Shoulder shrugging tests XI. Misidentifying this risks incorrect neurological assessment, potentially missing deficits in motor function, critical for diagnosing conditions affecting cranial nerve XI in clinical evaluations.
Choice B reason: Saying “light, tight, dynamite” tests cranial nerve XII (hypoglossal) for tongue movement, not XI, which involves shoulder and neck muscles. Assuming this assesses XI misguides neurological evaluation, risking oversight of motor weaknesses, essential for accurate diagnosis and management of cranial nerve-related disorders in patients.
Choice C reason: Identifying a smell tests cranial nerve I (olfactory), not XI, which governs shoulder and neck movements. Misidentifying this risks incorrect cranial nerve assessment, potentially missing motor deficits in XI, critical for diagnosing neurological conditions like nerve injuries or tumors affecting shoulder and neck function.
Choice D reason: Shrugging shoulders and turning the head against resistance tests cranial nerve XI (spinal accessory), assessing trapezius and sternocleidomastoid strength. This ensures accurate neurological evaluation, detecting deficits from nerve damage or lesions, guiding diagnosis and treatment, critical for managing motor function in patients with suspected cranial nerve issues.
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