While examining a client's mouth the nurse notes the presence of fasciculations, fine tremors of the client's tongue. How should the nurse best respond to the assessment finding?

Review the client's medication regimen

Have the client provide a 24-hr diet recall

Prepare the client for a thyroid screening

Assess the client's cranial nerve function

Answer and Explanation

The Correct Answer is D

Choice A reason: Medications like antipsychotics can cause tremors, but tongue fasciculations often signal neurological issues, not just drug effects. Reviewing regimen is secondary to assessing cranial nerve XII (hypoglossal), which controls tongue movement, for a more immediate etiology here.

Choice B reason: Diet recall might explore nutritional deficits, but tongue fasciculations tie to nerve or muscle pathology, not food intake. This lacks a direct link to neurological signs, making it less relevant than assessing nerve function for this specific finding fully.

Choice C reason: Thyroid issues cause coarse tremors, not fine fasciculations, which are more neuromuscular. Preparing for screening diverts from the priority of cranial nerve XII assessment, misaligning with the neurological basis of tongue movement observed in this examination entirely.

Choice D reason: Fasciculations suggest cranial nerve XII dysfunction, like in ALS or stroke, affecting tongue motor control. Assessing cranial nerves, especially hypoglossal, directly targets the finding’s neurological root, making it the best response to evaluate this abnormality accurately and promptly.

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Correct Answer is C

Explanation

Choice A reason: Ear candles are unsafe, risking burns or wax deeper in the canal. They don’t effectively remove cerumen and can perforate the eardrum, contradicting evidence-based hygiene practices for preventing ear infections or blockages entirely in this context.

Choice B reason: Irrigation with saline is for impacted cerumen, not routine hygiene. It’s a clinical procedure, not a daily prevention measure, and risks pushing wax further or damaging the canal if done improperly, making it less suitable here.

Choice C reason: Washing the pinna with a warm, moist washcloth safely cleans the outer ear, preventing debris buildup without risking the canal or eardrum. This simple, effective hygiene step aligns with illness prevention goals for routine ear care perfectly.

Choice D reason: Cotton swabs can push cerumen deeper, causing impaction or eardrum perforation. This unsafe practice increases infection risk, opposing hygiene goals, and is widely discouraged in favor of external cleaning for safe ear maintenance consistently.

A. Paraphimosis of prostate B. Epispadias C. Urethral stricture of bladder D. Age related changes

Correct Answer is B

Explanation

Choice A reason: Paraphimosis involves foreskin retraction, not meatal position, and isn’t prostate-related. Dorsal urethral meatus points to a congenital defect, not this acquired condition, making it an incorrect concern for this genitourinary finding entirely here fully.
Choice B reason: Epispadias is a congenital dorsal urethral opening, a key concern in males. This abnormal positioning may cause urinary issues or infertility, making it the most significant finding requiring attention in this assessment accurately and comprehensively here.
Choice C reason: Urethral stricture narrows the urethra, not shifting its position dorsally. This acquired issue isn’t bladder-specific, misaligning with the congenital anomaly observed, excluding it as the primary concern in this genitourinary exam fully here.
Choice D reason: Age doesn’t reposition the urethral meatus dorsally; this is congenital, not degenerative. Normal aging affects prostate size, not meatal anatomy, rendering this less critical than epispadias as the identified issue in this case entirely here.

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While examining a client's mouth the nurse notes the presence of fasciculations, fine tremors of the client's tongue. How should the nurse best respond to the assessment finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A health promotion teaching is focusing on hygiene and the prevention of illness. When instructing clients on how to clean their ears, what action should the nurse recommend?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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