While examining a client's mouth the nurse notes the presence of fasciculations, fine tremors of the client's tongue. How should the nurse best respond to the assessment finding?
Review the client's medication regimen
Have the client provide a 24-hr diet recall
Prepare the client for a thyroid screening
Assess the client's cranial nerve function
The Correct Answer is D
Choice A reason: Medications like antipsychotics can cause tremors, but tongue fasciculations often signal neurological issues, not just drug effects. Reviewing regimen is secondary to assessing cranial nerve XII (hypoglossal), which controls tongue movement, for a more immediate etiology here.
Choice B reason: Diet recall might explore nutritional deficits, but tongue fasciculations tie to nerve or muscle pathology, not food intake. This lacks a direct link to neurological signs, making it less relevant than assessing nerve function for this specific finding fully.
Choice C reason: Thyroid issues cause coarse tremors, not fine fasciculations, which are more neuromuscular. Preparing for screening diverts from the priority of cranial nerve XII assessment, misaligning with the neurological basis of tongue movement observed in this examination entirely.
Choice D reason: Fasciculations suggest cranial nerve XII dysfunction, like in ALS or stroke, affecting tongue motor control. Assessing cranial nerves, especially hypoglossal, directly targets the finding’s neurological root, making it the best response to evaluate this abnormality accurately and promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Graphesthesia tests parietal lobe sensory processing, not cerebellar function. The cerebellum coordinates movement, not cortical interpretation, making this irrelevant to assessing ataxia or balance issues expected in a cerebellar-focused exam entirely here fully.
Choice B reason: Stereognosis assesses parietal tactile recognition, not cerebellar motor control. This sensory test misses the cerebellum’s role in coordination and balance, excluding it as a priority for evaluating cerebellar dysfunction in this assessment comprehensively.
Choice C reason: Vibration tests posterior column sensation, not cerebellar function. While neurological, it targets spinal pathways, not the cerebellum’s coordination role, rendering it secondary to movement-based tests for cerebellar evaluation in this context fully here.
Choice D reason: Gait and balance directly assess cerebellar function, critical for coordination. Ataxia or wide-based gait from cerebellar damage makes this the priority test, aligning with the preceptor’s focus on cerebellar performance accurately and effectively here.
Correct Answer is D
Explanation
Choice A reason: PSA isn’t highly reliable alone; false positives occur. It’s a screening tool, not definitive, requiring biopsy for diagnosis, making this inaccurate and less informative than explaining its broader causes for this client fully here.
Choice B reason: PSA complements, not replaces, digital rectal exam (DRE). Both detect cancer; PSA misses some tumors DRE finds, rendering this false and incomplete for teaching screening essentials to a committed client entirely here fully.
Choice C reason: Annual PSA at 25 is too early; guidelines suggest 50, or 40-45 with family history. This overstates frequency and timing, misguiding the client on evidence-based screening practices for prostate cancer risk comprehensively here.
Choice D reason: PSA rises with cancer, BPH, or infection, educating the client on its non-specificity. This accurate teaching supports informed screening with family history, clarifying why follow-up is key, making it the best response accurately here.
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