The nurse is completing a neurological assessment on a client who suffered from a motor vehicle accident (MVA).

Which of the following findings should the nurse report to the practitioner immediately?

ability to swallow pureed foods

client reports mild headache

Weakness

Glasgow coma scale of 5

Answer and Explanation

The Correct Answer is D

A.   Ability to swallow pureed foods suggests some functional capacity and is not an immediate concern requiring immediate reporting.
B.   A mild headache reported by the client might not indicate a critical issue requiring immediate reporting.
C.   Weakness can be a concerning symptom, but the severity or extent of weakness needs further clarification before urgent reporting.
D.   A Glasgow Coma Scale (GCS) score of 5 is indicative of severe impairment of consciousness, requiring immediate attention and further evaluation by the healthcare provider.

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Correct Answer is C

Explanation

A. Estimating the degree of flexion and extension in each joint primarily assesses the range of motion, not specifically muscle strength.
B. Measuring the degree of force required to overcome joint flexion or extension may assess resistance but doesn't directly evaluate muscle strength.
C. Applying an opposing force when the individual puts a joint in flexion or extension is an accurate method to assess muscle strength, as it evaluates the force the muscle can generate against resistance.
D. Observing muscles for contraction while lifting a heavy object evaluates muscle usage but doesn’t offer a standardized way to assess muscle strength.

A. Listen to the client's speech. B. Ask them to read a Snellen chart. C. Ask them to identify scented aromas. D. Ask them to clench their teeth.

Correct Answer is D

Explanation

A. Listening to speech primarily involves cranial nerves related to speech production (e.g., CN V, CN VII, CN XII) but not specifically for CN V.
B. Reading a Snellen chart assesses visual acuity, primarily involving cranial nerve II (optic nerve).
C. Identifying scented aromas involves olfactory nerve (cranial nerve I) assessment.
D. Asking the client to clench their teeth evaluates the function of the muscles of mastication, which is controlled by cranial nerve V (trigeminal nerve).

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The nurse is completing a neurological assessment on a client who suffered from a motor vehicle accident (MVA). Which of the following findings should the nurse report to the practitioner immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to complete a muscle strength assessment on a client. Which of the following assessment techniques should the nurse utilize?

Correct Answer is C

Explanation

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve V?

Correct Answer is D

Explanation

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The nurse is completing a neurological assessment on a client who suffered from a motor vehicle accident (MVA).

Which of the following findings should the nurse report to the practitioner immediately?