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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Measuring the circumference of the ankle is not a specific method for screening DVT.
B. Assessing the calf at its widest point with a tape measure can reveal differences in calf size, which might indicate swelling due to a DVT.
C. Checking the dorsalis pedis pulse assesses peripheral circulation but doesn't specifically screen for DVT.
D. Compressing the dorsalis pedis pulse to check for blood return is part of assessing peripheral circulation but doesn’t directly screen for DVT.

A. Motor component of CN X and sensory component of CN VII B. Motor and sensory component of CN XI C. Motor component of CN IV D. Motor component of CN VII

Correct Answer is D

Explanation

A. Dysfunction of the motor component of CN X (vagus nerve) and sensory component of CN VII (facial nerve) would present with different symptoms, such as difficulty swallowing and impaired taste sensation, not the observed facial asymmetry and puffing of cheeks.
B. CN XI (accessory nerve) dysfunction primarily affects the sternocleidomastoid and trapezius muscles and wouldn't cause the observed facial asymmetry.
C. Dysfunction of CN IV (trochlear nerve) leads to issues with downward and inward eye movement, not the facial asymmetry described.
D. Dysfunction of the motor component of CN VII (facial nerve) leads to facial asymmetry during expressions and difficulty controlling facial muscles, which matches the observed findings.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to screen a client for deep vein thrombosis (DVT). Which of the following techniques should the nurse recognize as the appropriate technique to screen for DVT?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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

A client tells the nurse about being very unsteady and has difficulty in maintaining balance. The nurses recognize which area of the brain is involved and require further assessment.

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

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A client states, "I can hear a crunching or grating sound when I kneel and have difficulty getting out of bed in the morning because of pain and stiffness." Which of the following should the nurse expect as an assessment finding?

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