The client presents with a complaint of "always dropping things and falling down." During the neurologic assessment, the nurse notices the client is unable to perform rapid alternating movements. Instead the client's response is very slow and misses often. What neurologic dysfunction would the nurse suspect?
inability to understand directions
Lesion of cranial nerve IX
Dysfunction of the cerebellum
Vestibular disease
The Correct Answer is C
A. Inability to understand directions
The client's issue is with motor coordination, not comprehension.
B. Lesion of cranial nerve IX
Cranial nerve IX (Glossopharyngeal) is associated with swallowing and taste, not motor coordination.
C. Dysfunction of the cerebellum
The cerebellum controls coordination and fine motor movements. The client's inability to perform rapid alternating movements (dysdiadochokinesia) suggests cerebellar dysfunction.
D. Vestibular disease
Vestibular disorders cause dizziness, vertigo, and balance problems but do not typically affect rapid alternating movements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Notify the physician and anticipate the need for endotracheal intubation
The client is showing progressive airway obstruction due to inhalation injury. The absence of wheezes indicates impending respiratory failure, requiring immediate airway management.
B. Place the client in semi-Fowler's position and administer an albuterol breathing treatment
Albuterol may help bronchospasm, but this client's issue is upper airway swelling, not bronchospasm. Intubation is the priority.
C. Encourage the client to cough, take deep breaths, and then auscultate again
The loss of wheezes suggests airway swelling has worsened, not that secretions are the issue. Immediate intervention is needed.
D. Recommend a medical prescription for guaifenesin and encourage use of incentive spirometry
Guaifenesin and incentive spirometry help with secretion clearance, but they are not the priority in this emergent airway situation.
Correct Answer is B
Explanation
Parkland Formula:
Total fluid requirement (ml)=4×Body weight (kg)×Total body surface area burned (%TBSA)
= 4×70×70
=19,600mL (total for 24 hours)
Fluids in first 8 hours: 19,600mL÷2
=9,800mL
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