While obtaining a health history of a 3-month-old infant from the mother, the nurse asks about the infant’s ability to suck and grasp the mother’s finger. What is the nurse assessing?
Intelligence
Cerebral cortex function
Reflexes
Cranial nerves
The Correct Answer is C
Choice A reason: Intelligence cannot be assessed in a 3-month-old, as cognitive abilities are not yet developed enough for evaluation. Sucking and grasping are innate behaviors driven by reflexes, not conscious thought, making this an incorrect assessment focus.
Choice B reason: Cerebral cortex function is immature in a 3-month-old, and sucking and grasping are primarily brainstem-mediated reflexes. These actions do not directly assess higher cortical functions like memory or reasoning, making this an incorrect choice.
Choice C reason: Sucking and grasping in a 3-month-old are primitive reflexes (sucking reflex and palmar grasp reflex), mediated by the brainstem. Assessing these evaluates normal neurological development, making this the correct focus of the nurse’s inquiry.
Choice D reason: While sucking involves Cranial Nerves V, VII, IX, and XII, and grasping involves spinal reflexes, the nurse is assessing the presence of these reflexes, not the cranial nerves directly. Reflex assessment is the primary focus, making this less precise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Deep-vein thrombophlebitis involves deep vein inflammation and clotting, causing pain, swelling, and warmth, but not typically visible dilated veins. The described tortuous veins are superficial, not deep, making this an incorrect diagnosis for the findings.
Choice B reason: Varicose veins are dilated, tortuous superficial veins, often in the lower legs, causing heaviness or aching. These result from venous insufficiency, leading to blood pooling, which matches the patient’s visible veins and symptoms, making this correct.
Choice C reason: Peripheral artery disease causes reduced arterial blood flow, leading to pain, pallor, or claudication, not dilated veins. The visible tortuous veins suggest a venous issue, not arterial, making this an incorrect condition for the findings.
Choice D reason: Chronic lymphedema causes swelling due to lymphatic fluid accumulation, typically without dilated veins. The patient’s tortuous veins and heaviness point to venous pathology, not lymphatic, making this an incorrect diagnosis for the described symptoms.
Correct Answer is D
Explanation
Choice A reason: There is no standard “grade 5” in tonsil size grading. The scale typically ranges from 0 to 4+, with 4+ indicating tonsils touching or overlapping, making this an incorrect and non-standard documentation term.
Choice B reason: Grade 3 tonsils are enlarged, occupying about 75% of the pharyngeal space, but not touching. The described tonsils are touching, which corresponds to a higher grade, making grade 3 incorrect for this finding.
Choice C reason: Grade 2+ tonsils are moderately enlarged, taking up about 50% of the pharyngeal space. The tonsils touching indicate a more severe enlargement, aligning with a higher grade, making this an incorrect documentation choice.
Choice D reason: Grade 4+ tonsils are severely enlarged, touching or overlapping in the midline, as described. This matches the standard tonsil grading scale, where 4+ indicates maximal swelling, making this the correct documentation.
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