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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Hyperthyroidism may cause eye issues like exophthalmos, not cataracts. Lens opacity from aging or smoking outweighs thyroid risk, making this 55-year-old less prioritized for cataract screening than older, smoking-exposed clients in this context fully.
Choice B reason: Minimal alcohol (two beers weekly) at 30 poses no cataract risk. Age and smoking are stronger factors; this young client lacks the cumulative exposure or oxidative stress tied to lens clouding, excluding them entirely here.
Choice C reason: At 75, with 50 years of smoking, this client faces high cataract risk. Aging degrades lens proteins, and smoking’s oxidative damage accelerates opacity, making this the priority for assessment and education on cataract prevention accurately here.
Choice D reason: Arteriosclerosis at 40 affects vessels, not lenses directly. While vascular health matters, age and smoking outweigh this risk for cataracts, rendering this client lower priority than the older, heavily smoking individual in this scenario fully.

A. Prolonged tonsillar enlargement B. History of allergies C. Incomplete immunization record D. History of epistaxis nosebleeds

Correct Answer is B

Explanation

Choice A reason: Prolonged tonsillar enlargement may cause throat issues or obstruction, but rhinorrhea stems from nasal inflammation, not tonsils. This focuses on oropharyngeal anatomy, missing the direct nasal etiology tied to runny nose in upper airway complaints here entirely.

Choice B reason: Allergies trigger nasal inflammation via histamine, causing rhinorrhea as IgE-mediated mast cells release mediators. A history of this is key, directly linking environmental triggers to the client’s runny nose, making it the most relevant assessment area accurately.

Choice C reason: Incomplete immunizations increase infection risk, but rhinorrhea more commonly ties to allergies or viruses than vaccine-preventable diseases here. This is less specific to the symptom’s etiology without fever or systemic signs, reducing its pertinence significantly.

Choice D reason: Epistaxis (nosebleeds) relates to vascular fragility, not mucus production like rhinorrhea. Past bleeding doesn’t explain runny nose, focusing on a separate nasal issue, making it less relevant to the upper airway complaint’s root cause in this case fully.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea?

Correct Answer is B

Explanation

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