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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Inspection visually assesses abdominal shape and distention but cannot differentiate gas from constipation, as both may cause distention. It lacks the specificity to identify the cause, making it less effective for this purpose.

Choice B reason: Auscultation assesses bowel sounds but cannot directly distinguish gas from constipation. Hyperactive sounds may suggest gas, but this is indirect, and constipation can also alter sounds, making this less specific than percussion.

Choice C reason: Percussion produces a tympanic sound over gas-filled areas, indicating air in the bowel, versus a dull sound over solid masses like feces in constipation. This directly differentiates the cause of distention, making it the correct technique.

Choice D reason: Palpation assesses tenderness or masses but cannot reliably distinguish gas from constipation, as both may feel firm or distended. It lacks the specificity of percussion’s auditory cues, making it less effective for this purpose.

A. Bronchial breath sounds that are normal in that location B. Normal sounds auscultated over the trachea C. Vesicular breath sounds that are normal in that location D. Bronchovesicular breath sounds that are normal in that location

Correct Answer is C

Explanation

Choice A reason: Bronchial breath sounds are loud, high-pitched, with expiration longer than inspiration, typically heard over the trachea or in consolidated lung areas. The described soft, low-pitched sounds with longer inspiration in the posterior lower lobes do not match, making this incorrect.

Choice B reason: Sounds over the trachea are bronchial, characterized by loud, high-pitched sounds with expiration equal to or longer than inspiration. The soft, low-pitched sounds with longer inspiration in the posterior lower lobes indicate peripheral lung fields, not tracheal sounds, making this incorrect.

Choice C reason: Vesicular breath sounds are soft, low-pitched, with inspiration longer than expiration, heard over peripheral lung fields like the posterior lower lobes. These are normal findings, reflecting air movement in alveoli, making this the correct interpretation of the described sounds.

Choice D reason: Bronchovesicular sounds are medium-pitched with equal inspiration and expiration, typically heard near mainstem bronchi. The described low-pitched sounds with longer inspiration in the posterior lower lobes align with vesicular sounds, not bronchovesicular, making this incorrect.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse assesses a patient’s abdomen. Which examination technique would aid the nurse in determining whether gas (air) in the bowel is causing distention rather than constipation?

Correct Answer is C

Explanation

When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. How should the nurse interpret these findings?

Correct Answer is C

Explanation

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