When performing an assessment, the nurse observes for bilateral equality. After performing a neurological assessment, which of the following will the nurse document when assessment findings indicate that there is left facial droop?
Inability to perform within normal limits
Symmetrical findings
Asymmetrical findings
Bilateral strength present
The Correct Answer is C
Choice A Reason: This choice is incorrect. Inability to perform within normal limits is a vague and general term that does not describe the specific finding of left facial droop. The nurse should document the exact observation and compare it to the expected or normal range.
Choice B Reason: This choice is incorrect. Symmetrical findings mean that both sides of the body or face are equal or similar in appearance or function. Left facial droop indicates that one side of the face is lower or weaker than the other, which is not symmetrical.
Choice C Reason: This is the correct choice. Asymmetrical findings mean that both sides of the body or face are unequal or different in appearance or function. Left facial droop indicates that one side of the face is lower or weaker than the other, which is asymmetrical.
Choice D Reason: This choice is incorrect. Bilateral strength present means that both sides of the body or face have normal or adequate muscle power or force. Left facial droop indicates that one side of the face has reduced or impaired muscle power or force, which is not bilateral strength present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Decreased thickness of tympanic membranes is not a physiological change to hearing in older adult clients. The tympanic membranes are thin and flexible structures that vibrate in response to sound waves. The thickness of the tympanic membranes does not change significantly with age.
Choice B Reason: Decreased tinnitus is not a physiological change to hearing in older adult clients. Tinnitus is a ringing or buzzing sound in the ears that may be caused by various factors, such as noise exposure, ear infections, medications, or aging. Tinnitus may increase or decrease with age, depending on the underlying cause.
Choice C Reason: Decreased ear wax is not a physiological change to hearing in older adult clients. Ear wax is a natural substance that lubricates and protects the ear canal from dust, bacteria, and insects. Ear wax production may vary with age, but it does not affect hearing unless it accumulates and blocks the ear canal.
Choice D Reason: Decreased ability to hear high-frequency sounds is a physiological change to hearing in older adult clients. This is also known as presbycusis, which is a gradual loss of hearing that occurs as part of aging. Presbycusis affects the ability to hear high-pitched sounds, such as consonants, birdsong, or alarms.
Correct Answer is B
Explanation
Choice A reason: This is incorrect because loss of peripheral vision is not a manifestation of cataracts, but of glaucoma. Glaucoma is a condition that causes increased pressure inside the eye and damage to the optic nerve, which can lead to loss of vision in the outer edges of the visual field. The nurse should assess the client's intraocular pressure and visual field test results to rule out glaucoma.
Choice B reason: This is correct because a decreased ability to perceive colors is a manifestation of cataracts. Cataracts are a condition that causes clouding or opacity of the lens, which is the transparent structure behind the pupil that focuses light onto the retina. Cataracts can reduce the clarity and contrast of vision and make colors appear faded or yellowish. The nurse should ask the client about any changes in color perception or brightness of objects.
Choice C reason: This is incorrect because loss of central vision is not a manifestation of cataracts but of macular degeneration. Macular degeneration is a condition that affects the macula, which is the central part of the retina that is responsible for sharp and detailed vision. Macular degeneration can cause blurred or distorted central vision, difficulty reading or recognizing faces, or dark spots in the visual field. The nurse should assess the client's visual acuity and fundoscopic examination results to rule out macular degeneration.
Choice D reason: This is incorrect because seeing bright flashes of light and floaters is not a manifestation of cataracts but of retinal detachment. Retinal detachment is a condition that occurs when the retina, which is the layer of tissue at the back of the eye that converts light into nerve impulses, separates from its underlying support tissue. Retinal detachment can cause sudden flashes of light, floaters, or shadows in the visual field. The nurse should refer the client to an ophthalmologist immediately if retinal detachment is suspected.
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