After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? Select all that apply.

Asked the client to swallow

Asked the client to extend the tongue

Asked the client to rock the jaw laterally

Asked the client to open and close the mouth

Asked the client to jut the jaw forward

Answer and Explanation

Correct Answer : C,D,E

A.   Swallowing involves the muscles of the throat and esophagus rather than the TMJ.
B.   Extending the tongue involves the muscles of the tongue and mouth, which are not directly related to the TMJ.
C.   Rocking the jaw laterally (side to side) is a specific movement that involves the TMJ. This movement tests the ability of the TMJ to move the jaw from side to side.
D.   Opening and closing the mouth involves the primary hinge movement of the TMJ. This movement assesses the vertical range of motion of the jaw.
E.   Jutting the jaw forward (protrusion) involves moving the lower jaw forward in relation to the upper jaw. This movement tests the ability of the TMJ to perform anterior movement.

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Correct Answer is A

Explanation

A. Decorticate rigidity is characterized by flexion of the arms and extension of the legs. In this posture, the upper arms are flexed and held tightly to the sides, with the elbows, wrists, and fingers also flexed. The legs are extended and internally rotated.
B. Flaccid posture, or flaccidity, is characterized by a complete lack of muscle tone, which leads to a limp and lifeless appearance. There is no resistance to passive movement, and the muscles are weak or paralyzed.

C. Decerebrate rigidity is characterized by extension of both the arms and the legs. In this posture, the arms are extended at the sides with the wrists and fingers flexed, and the legs are extended and internally rotated. This type of rigidity indicates damage to the brainstem below the red nucleus.
D. Hemiplegia refers to paralysis of one side of the body, which can result from brain injury or stroke affecting one hemisphere of the brain. The affected side will have limited or no movement and muscle tone.

A. Concentration B. Attention C. Affect D. Abstract reasoning

Correct Answer is D

Explanation

A. Concentration refers to the ability to focus on a specific task or thought for a period of time. While concentration is important for cognitive functioning, it is not the specific skill being assessed when interpreting the meaning of a proverb.
B. Attention is the ability to focus and direct mental resources towards a specific task or stimulus. While attention is necessary for understanding and processing information, the task of interpreting a proverb is more related to higher-level cognitive processes rather than just the ability to maintain focus.
C. Affect refers to the emotional state or mood of a person. It involves how emotions are expressed and experienced. Assessing affect involves observing the client’s emotional responses, not their ability to interpret abstract concepts. Therefore, affect is not the focus of this assessment.
D. Abstract reasoning is the ability to understand and interpret concepts and ideas that are not directly observable or tangible. It involves thinking beyond concrete facts to understand underlying meanings, patterns, and relationships. Interpreting a proverb, which involves understanding a figurative meaning rather than a literal one, is a test of abstract reasoning. The ability to grasp the deeper meaning behind “A penny saved is a penny earned” reflects the client's capacity for abstract reasoning.

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After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? Select all that apply.

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Naxlex Comprehensive Predictor Exams

In the Neuro ICU, a comatose patient has this posture in bed: Upper arms are flexed tight to the sides with elbows, wrists, and fingers flexed. The legs are extended and internally rotated. The nurse interprets this posture as:

Correct Answer is A

Explanation

During an assessment, the nurse asks a client to explain what the following means: "A penny saved is a penny earned." The nurse is assessing which of the following?

Correct Answer is D

Explanation

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