While conducting an assessment the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating?

perseveration

flight of ideas

derailment

confabulation

negative Babinski reflex

Answer and Explanation

The Correct Answer is D

A.   Perseveration refers to the repetition of a particular response or behavior despite the cessation of the stimulus that prompted it. This often occurs in individuals with neurological disorders, where they keep repeating the same word, phrase, or action.
B.   Flight of ideas is a rapid flow of thoughts where the person moves quickly from one topic to another, often with tangential or disconnected ideas. It is commonly observed in conditions such as mania or hypomania.
C.   Derailment, also known as loosening of associations, is a thought disorder where a person’s speech goes off-topic and seems disorganized. The connections between ideas are loose or fragmented, making the conversation difficult to follow.
D.   Confabulation is a memory disturbance where a person creates false memories or fabricated details to fill in gaps in their memory. The individual does not intentionally deceive but genuinely believes their fabricated information is true.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. The trigeminal nerve (CN V) primarily controls sensation in the face and the muscles of mastication (chewing). While it is crucial for sensory input and motor control related to chewing, it does not directly control the movement of the tongue.
B. The hypoglossal nerve (CN XII) is responsible for controlling the movements of the tongue. A lesion of CN XII can cause the tongue to deviate towards the side of the weakness or damage. This is because the hypoglossal nerve innervates the muscles of the tongue, and damage to it results in weakness of the muscles on the affected side, causing the tongue to deviate towards that side when protruded.
C. The facial nerve (CN VII) controls the muscles of facial expression. While it affects facial movements and expressions, it does not control the movements of the tongue. A lesion in CN VII would typically result in facial asymmetry or weakness rather than tongue deviation.
D. The olfactory nerve (CN I) is responsible for the sense of smell. It does not have any role in controlling tongue movement. Therefore, a lesion in CN I would not cause deviation of the tongue.

A. Glossopharyngeal B. Trigeminal C. Vagus D. Facial

Correct Answer is B

Explanation

A. The glossopharyngeal nerve is involved in several functions, including taste sensation on the posterior third of the tongue, salivation, and the sensation of the pharynx. It also plays a role in swallowing and gag reflex. However, it is not responsible for the movement of the jaw or clenching of the jaw.
B. The trigeminal nerve is responsible for sensation in the face and also controls the muscles of mastication (chewing). It has both sensory and motor functions. The motor branches of the trigeminal nerve, specifically the mandibular division, innervate the muscles that allow for jaw movement, including clenching.
C. The vagus nerve has a broad range of functions, including regulating heart rate, digestive tract motility, and some aspects of speech and swallowing. It does not control jaw movement or clenching, so it is not relevant to this observation.
D. The facial nerve controls the muscles of facial expression, including movements like smiling, frowning, and closing the eyes. It is not involved in the motor control of the jaw or clenching actions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

While conducting an assessment the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a physical examination on a patient. When the patient is asked to protrude his tongue, the nurse noticed a deviation from the midline to the right side. This is related to a lesion of:

Correct Answer is B

Explanation

A client is clenching the jaw closed to avoid taking a prescribed oral medication. The nurse can use this observation to confirm the client is demonstrating motor function of which cranial nerve?

Correct Answer is B

Explanation

When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding?

During an assessment, the nurse asks a client to explain what the following means: "A penny saved is a penny earned." The nurse is assessing which of the following?

Which are the 3 areas included in the Glasgow Coma Scale to assess levels of consciousness? Select all that Apply.

Loss of bone density that occurs with greatest frequency in postmenopausal women is called?

A client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding?

In the Neuro ICU (intensive care unit) while performing a neurological assessment of the patient the nurse noticed the patient: patient opens eyes, looks at you, responds slowly, and is somewhat confused. What level of consciousness (LOC) is this patient presenting?

A nurse is conducting a health history with a client who has recently had a stroke. The nurse notes the client is unable to speak, although his comprehension/ understanding is intact. Which disorder of speech is the nurse observing in this client?

The nurse places a coin in the patient's hand, the patient is with eyes closed. The ability to identify an object by feeling it is defined as: