NUR 3255 physical assessment module 8 quiz Latest 2022,100% CORRECT

NUR 3255 physical assessment module 8 quiz Latest 2022 1. A client complaints of inability to move tongue. what is the most appropriate action for the nurse to take? a. evaluate function of the facial nerve. b. test for sensory function. c. test the hypoglossal nerve. d. prepare the client for a ct scan 2. when assessing muscle tone, the nurse will passively move the clients limbs into different positions. what is the expected normal response? a. stiffness with resistance to movement b. flaccid limbs. c. slight resistance as action performed. d. pain on movement. 3. the nurse is performing the romberg test, the client starts to sway and moves their feet farther apart. how would this be documented? a. normal. b. lack of coordination c. positive romberg sign d. negative homan's sign 4. during examination of a client with a brain tumor, the nurse finds that the client is unable to identify a number ''3'' drawn in the palm of their hand. what test has the nurse been performing? a. stereognosis b. extinction c. graphesthesia d. point location 5. what are the routine components included in a neurological recheck exam. select all that apply. a. vital signs b. cranial nerves c. motor function d. rinne test e. pupillary response. f. level of consciousness. 6. what components are tested with Glasgow coma scale. a. motor, eye opening, verbal response b. memory, motor, eye opening c. eye opening, motor, sensory d. verbal response, eye opening, orientation 7. the nurse documents the bilateral patellar or quadriceps reflexes on a client to be 3+. what does that indicate? a. average, normal b. brisker than average c. diminished, low normal d. very brisk, hyperactive with clonus 8. the nurse is assessing cranial nerve XI (spinal accessory), what should the nurse instruct the client to do. a. stick out your tongue and move it from side to side b. shrug your shoulders as I push down on them c. taste these foods and tell me which is sweet and which is sour d. smell these items and identify what they are 9. The nurse inspects and palpates the throat as the client swallows. which cranial nerve is being tested? a. IX glossopharyngeal b. X vagus c. VII facial d. XII hypoglossal 10.a nurse is performing an admission assessment on newly admitted client . The client states, "I am very unsteady on my feet". what assessment would the nurse perform to evaluate the client's statement? a. test the client's intellectual functioning by asking the client to remember several sequence of numbers b. perform assessment to evaluate cerebral function c. assess the client for two point discrimination d. test ocular fields to see if there is a visual problem causing the unsteadiness 11. what is considered to be an abnormal finding in adult when performing the planter flex a. flexion response b. babinski response c. globular response d. ankle clonus 12.A client has an impairment of cranial nerve II. specific to this impairment, what would the nurse plan to do to ensure client safety? a. provide a clear path for ambulation without obstacles b. test the temperature of the shower water c. confirm the consistency of the food on the dietary tray is soft mechanical consistency d. speak loudly to the client 13. Which statement is true regarding the Glasgow coma scale? a. it is based on vital signs, speech ability, and memory b. it assesses the functional ability of the client c. it indicates if there is damage specifically to the frontal lobe to the brain d. it is quantitative method to define the level of conscious of the client 14.What response would be expected upon testing the triceps reflex? a. flexion of the hand b. extension of the forearm c. involuntary movement of the fingers d. pronation of the hand 15. What would the nurse test to determine functioning of cranial nerve X, vagus nerve? a. perform the confrontation b. have client say "ah" and watch uvula c. check the gag reflex d. have client stick out their tongue and wiggle it 16. Which assessment would be appropriate for evaluating cerebellar function? a. dull/sharp testing b. tandem/heel to toe walk c. testing cranial nerve VII d. stereognosis 17. The client comes to the clinic complaining of drooping of the left side of the mouth. which cranial nerve should the nurse assess? a. oculomotor nerve, cranial nerve III b. facial nerve, cranial nerve VII c. Olfactory, cranial nerve I d. Optic nerve, cranial nerve II 18. The nurse is assessing a client's neurological status by touching a wisp of cotton in various places on the face to see if the client can sense it, what cranial nerve is being tested? a. CN III b. CN V c. CN VII d. CN IX 19. To evaluate the patellar reflex, the nurse would do which of the following? select all that apply a. use distraction like having them try to pull their grasped hands apart b. palpate the patella to locate strike location c. position the client on their back d. strike just below the patella with a reflex hammer e. have the client flex their foot on the tested side does stereognosis assess? a. sharp and dull sensation b. ability to identify objects by feel c. vibratory sense d. light touch