While assessing the client's gait during, which of the following would indicate a need for further evaluation?

Feet stay parallel when moving forward.

Heels strike the ground before the toes.

Reses each foot off the floor with each step.

Right arm and leg move forward together

Answer and Explanation

The Correct Answer is D

A.   This is a normal finding in gait, as the feet should typically remain parallel while walking.
B.   Heels strike the ground before the toes. This is a normal gait pattern, especially in elderly individuals, where a heel-to-toe walk is common.
C.   Reses each foot off the floor with each step. This is a normal finding, as the person should lift their foot off the ground while walking.
D.   Right arm and leg move forward together. This is an abnormal finding, indicating a possible neurological issue such as hemiparesis or other gait disturbance, which warrants further evaluation.

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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).

A. Constriction of pupils and convergence of eyes bilaterally B. Dilation of pupils and convergence of eyes bilaterally C. Nystagmus when object is moved close to the client's nose D. No change in pupil size and parallel alignment of both eyes

Correct Answer is A

Explanation

A. This is the expected response when assessing accommodation. The pupils should constrict (become smaller) and the eyes should converge (move inward) as a person focuses on a near object.
B. This response is not typical for accommodation. Convergence should occur with pupil constriction when focusing on a near object.
C. Nystagmus (a rhythmic jerking of the eyes) is not a normal finding during accommodation testing. It could indicate neurological or vestibular issues.
D. This is not a typical accommodation response. The pupils should constrict, and the eyes should converge when focusing on a near object.

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While assessing the client's gait during, which of the following would indicate a need for further evaluation?

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Naxlex Comprehensive Predictor Exams

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

Which of the following would be considered an expected finding when assessing accommodation in an adult client?

Correct Answer is A

Explanation

A newly admitted patient is having generalized anxiety, headache with pain level 4/10, and shortness of breath at rest. How should the nurse prioritize these problems?

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