A nurse is working with a client who has a history of headaches for greater than two months. When preparing to assess the client's temporomandibular joint, what instruction provided to the client would indicate the nurse needs more teaching?

"I am going to place my hand on your cheek, and I want you to turn your head against resistance."

"I’m going to place my fingers in front of your ear, and I want you to open your mouth as wide as possible."

"I want you to move your jaw from side to side and tell me if there is any pain with the movement."

"Push out and pull in your lower jaw and let me know if you experience popping or grating."

Answer and Explanation

The Correct Answer is A

Choice A reason: Turning the head against resistance assesses neck muscles, not the temporomandibular joint (TMJ), which hinges the jaw. TMJ evaluation requires jaw-specific movements, not cervical rotation, indicating a misunderstanding of TMJ anatomy and function, misaligning with headache assessment needs.

Choice B reason: Opening the mouth wide while fingers are placed near the ear directly tests TMJ range of motion and joint integrity. This is a standard technique to detect dysfunction or pain, correctly targeting the jaw’s articulation point relevant to headaches.

Choice C reason: Moving the jaw side to side evaluates TMJ lateral excursion, a key diagnostic motion. Pain reporting during this action helps identify joint issues tied to chronic headaches, making it an appropriate and precise instruction for TMJ assessment.

Choice D reason: Pushing out and pulling in the jaw tests TMJ protrusion and retraction, critical for assessing joint stability and sounds like popping, which may link to headache etiology. This instruction correctly focuses on TMJ mechanics and symptoms.

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Correct Answer is C

Explanation

Choice A reason: Thin, gray-white discharge suggests infection like bacterial vaginosis, not menopause. Menopause features dryness, not discharge, making this unrelated to hormonal decline, excluding it as a trigger for menopause education in this case fully here.
Choice B reason: Urinary difficulty may relate to aging or prolapse, not directly menopause. While estrogen loss can affect the urethra, it’s less specific than vaginal symptoms, rendering it secondary for menopause-focused education entirely and accurately here.
Choice C reason: Irregular bleeding and vaginal dryness are hallmark menopause signs, from estrogen drop. Perimenopause causes erratic periods, and dryness reflects atrophy, making this the key finding for targeted menopause education comprehensively and accurately here.
Choice D reason: Painless vaginal lumps suggest cysts or tumors, not menopause. These structural issues lack hormonal ties to estrogen decline, excluding them as menopause indicators needing education compared to bleeding and dryness fully here entirely.

A. VIII B. XII C. VI D. III

Correct Answer is B

Explanation

Choice A reason: Cranial nerve VIII (vestibulocochlear) governs hearing and balance, not tongue strength. A deficit here causes vertigo or deafness, not motor weakness in the tongue, making it unrelated to the observed decrease in muscle power during examination.
Choice B reason: Cranial nerve XII (hypoglossal) controls tongue movement and strength. Weakness here, as noted, suggests nerve damage, like in stroke or ALS, impairing the tongue’s ability to push against resistance, directly explaining the finding accurately.
Choice C reason: Cranial nerve VI (abducens) moves the eye laterally, not the tongue. A problem here causes diplopia, not tongue weakness, disconnecting it from the motor function loss observed in the client’s oral examination entirely here.
Choice D reason: Cranial nerve III (oculomotor) controls eye movement and pupil response, not tongue strength. Its dysfunction leads to ptosis or eye deviation, irrelevant to the tongue’s motor impairment noted in this neurological assessment fully.

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A nurse is working with a client who has a history of headaches for greater than two months. When preparing to assess the client's temporomandibular joint, what instruction provided to the client would indicate the nurse needs more teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing a subjective data assessment for an older female. The client verbalizes a list of symptoms regarding their concern. Which findings would lead the nurse to supply education about menopause?

Correct Answer is C

Explanation

A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve?

Correct Answer is B

Explanation

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