The nurse is performing a neurological assessment on a client with a history of Diabetes.
When testing the ability to feel the vibrations of a tuning fork, the nurse notices that the client is unable to feel vibrations on the great toe or ankle bilaterally, but is able to feel vibrations on both patellae. What should the nurse suspect from these assessments?
Hyperalgesia
Peripheral neuropathy
Hyperparalysis
Lesion of the sensory cortex
The Correct Answer is B
A. Hyperalgesia refers to increased sensitivity to pain stimuli, not specifically related to the inability to feel vibrations.
B. Peripheral neuropathy, a common complication of diabetes, often leads to sensory deficits, especially in distal extremities like the toes and feet.
C. Hyperparalysis is not a recognized term in neurology.
D. A lesion of the sensory cortex would likely present with broader sensory deficits rather than a specific loss of vibration sensation in the distal lower extremities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Vertigo is the sensation of spinning or movement when stationary and is often associated with inner ear problems.
B. Seizure activity involves abnormal electrical activity in the brain and might present with various symptoms but not necessarily the feeling of spinning.
C. Dizziness is a more general term that can include feelings of light-headedness or unsteadiness without a specific spinning sensation.
D. Syncope refers to fainting or loss of consciousness due to decreased blood flow to the brain, not the sensation of spinning.
Correct Answer is D
Explanation
A. Listening to speech primarily assesses cranial nerves related to speech and articulation, not cranial nerve II.
B. Identifying scented aromas assesses the olfactory nerve.
C. Clenching teeth primarily assess cranial nerve V (trigeminal nerve).
D. Cranial nerve II is the optic nerve responsible for vision. Testing visual acuity using a Snellen chart assesses this nerve's function.
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