A client describes a 3-week history of hoarseness. The client also reports feeling fatigue and noticeable weight gain over the past month. Which cause should the nurse consider as most likely?

Hypothyroidism

Gingivitis

Aphthous ulcers

Dysphagia

Answer and Explanation

The Correct Answer is A

Choice a reason:
Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormones. This can lead to a variety of symptoms, including hoarseness, fatigue, and weight gain. The hoarseness can be due to the effect of hormone deficiency on the vocal cords, while fatigue and weight gain are common due to the slowed metabolism associated with hypothyroidism.

Choice b reason:
Gingivitis is inflammation of the gums and does not typically cause hoarseness, fatigue, or weight gain. It is more commonly associated with symptoms like red, swollen gums and bleeding during brushing or flossing.

Choice c reason:
Aphthous ulcers, also known as canker sores, are small, shallow lesions that develop on the soft tissues in the mouth or at the base of the gums. While they can be painful and cause difficulty with eating and speaking, they do not cause systemic symptoms such as hoarseness, fatigue, or weight gain.

Choice d reason:
Dysphagia, or difficulty swallowing, can lead to hoarseness if there is an associated throat disorder. However, it is not typically associated with systemic symptoms like fatigue and weight gain unless it is part of a broader condition that affects the body's metabolism or energy levels.

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Correct Answer is B

Explanation

Choice a reason:
Draping body areas that are not being assessed is important for maintaining the client's privacy and comfort, but it is not the highest priority when dealing with a client with generalized muscle weakness. The primary concern is to prevent further strain or injury during the examination.

Choice b reason:
Limiting position changes as much as possible is the priority when examining a client with generalized muscle weakness. Frequent or unnecessary movements can cause fatigue, discomfort, and may even be unsafe if the client has severely compromised muscle strength. The nurse should plan the examination to minimize the number of times the client needs to change positions.

Choice c reason:
Hand-washing throughout the exam is a standard practice to prevent the spread of infection. While it is crucial for both the client's and the nurse's safety, in the context of a client with generalized muscle weakness, the priority is to conduct the exam in a way that does not exacerbate the client's condition.

Choice d reason:
Using alcohol swabs to clean the stethoscope before and after the exam is also a standard infection control practice. However, it is not the most immediate concern when prioritizing the steps of a physical examination for a client with muscle weakness.

A. Facial B. Abducens C. Glossopharyngeal D. Hypoglossal

Correct Answer is C

Explanation

Choice A Reason:
The facial nerve, or cranial nerve VII, is responsible for the taste sensation in the anterior two-thirds of the tongue, not the posterior third. It carries taste sensations from the front part of the tongue via the chorda tympani branch.

Choice B Reason:
The abducens nerve, or cranial nerve VI, has no role in taste sensation. It is primarily involved in controlling the lateral rectus muscle of the eye, which abducts the eye.

Choice C Reason:
The glossopharyngeal nerve, or cranial nerve IX, provides special sensory innervation for taste to the posterior third of the tongue. This enables the sensation of various tastes like salty, sweet, sour, and bitter in this region.

Choice D Reason:
The hypoglossal nerve, or cranial nerve XII, is responsible for motor control of the tongue muscles but does not provide sensory innervation for taste.

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A client describes a 3-week history of hoarseness. The client also reports feeling fatigue and noticeable weight gain over the past month. Which cause should the nurse consider as most likely?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When conducting a physical examination of a client with generalized muscle weakness, which of the following is the PRIORITY for the nurse?

Correct Answer is B

Explanation

What cranial nerve is responsible for the taste sensation of the posterior third of the tongue?

Correct Answer is C

Explanation

A middle-aged school teacher complains of excessive tearing of the eyes every morning. Which assessment should the nurse perform next?

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While auscultating a client's 1st and 2nd intercostal spaces, close to the sternal body, the nurse would document these normal breath sounds as which of the following?

The nurse is preparing to auscultate the lung sounds of a young adult. Which sound will the nurse expect to hear over most of the client's lungs?

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply)