The nurse is testing for motor functioning by having the client lie down and slide the heel of the right foot down the left shin and then slide the heel of the left foot down the right shin. Which response by the patient would indicate that there may be cerebellar dysfunction?
Rapid oscillations of the ankle
Deviation of the heel to one side
Pain and flexion in the knee
The client reports paresthesia
The Correct Answer is B
Choice A reason: Rapid ankle oscillations might suggest tremor, possibly basal ganglia issues, not cerebellar dysfunction. The heel-shin test assesses coordination, where cerebellar damage causes drift, not rhythmic shaking, making this less indicative of the target pathology here.
Choice B reason: Heel deviation to one side in the heel-shin test signals cerebellar dysfunction, impairing coordination. The cerebellum fine-tunes movement; damage causes ataxia, leading to inaccurate sliding, making this the key sign of cerebellar issues accurately.
Choice C reason: Pain and knee flexion suggest joint or nerve issues, not cerebellar dysfunction. This test evaluates smooth motion, not pain response; cerebellar problems show ataxia, not discomfort, disconnecting this from the intended motor assessment fully.
Choice D reason: Paresthesia (tingling) indicates sensory nerve issues, not cerebellar motor control. The cerebellum coordinates movement, not sensation; this response misses the coordination focus of the heel-shin test, excluding it as a cerebellar sign here entirely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Ear candles are unsafe, risking burns or wax deeper in the canal. They don’t effectively remove cerumen and can perforate the eardrum, contradicting evidence-based hygiene practices for preventing ear infections or blockages entirely in this context.
Choice B reason: Irrigation with saline is for impacted cerumen, not routine hygiene. It’s a clinical procedure, not a daily prevention measure, and risks pushing wax further or damaging the canal if done improperly, making it less suitable here.
Choice C reason: Washing the pinna with a warm, moist washcloth safely cleans the outer ear, preventing debris buildup without risking the canal or eardrum. This simple, effective hygiene step aligns with illness prevention goals for routine ear care perfectly.
Choice D reason: Cotton swabs can push cerumen deeper, causing impaction or eardrum perforation. This unsafe practice increases infection risk, opposing hygiene goals, and is widely discouraged in favor of external cleaning for safe ear maintenance consistently.
Correct Answer is D
Explanation
Choice A reason: Cerebral stagger isn’t a standard term; cerebral damage might cause spasticity, not wide-based ataxia. This lacks specificity for cerebellar signs like staggering, misaligning with the broad, unsteady gait tied to coordination loss in this client fully.
Choice B reason: Scissors gait, from cerebral palsy, shows stiff, crossed legs, not wide-based staggering. This spastic pattern contrasts with the unsteady, broad stance of cerebellar dysfunction, excluding it as the correct description for this presentation entirely here.
Choice C reason: Parkinsonian gait is shuffling with small steps and rigidity, not wide-based or staggering. This contrasts with the unsteady, broad stance of cerebellar ataxia, making it an incorrect match for the client’s observed walking pattern fully here.
Choice D reason: Cerebellar ataxia causes a wide-based, staggering gait due to coordination loss from cerebellar damage. This matches the client’s unsteady walk, reflecting impaired balance and motor control, accurately describing the observed gait pattern comprehensively here.
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