Health Assessment

What are the symptoms of a stroke?

1) Sudden weakness or numbness of the face, arm and leg, usually on one side of the body. 2) Difficulty talking or understanding speech 3) Dimness or loss of vision on one eye 4) Unexplained dizziness and unsteadiness 5) Falls 6) Sudden severe headache

Which of the following would be normal in the aging adult?

1. loss of muscle bulk 2. loss of muscle tone in face 3. impaired cognitive agility 4. decreased achilles reflex 5. decreased pupillary reflex

What is the cranial nerve that assesses the mastication muscles?

1.Cranial nerve(V) Trigeminal Nerve

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?

3. Transport the victim to the operating room for surgery.

Most facial bones articulate at a suture. Which facial bone articulates at a joint?

-Mandible The facial bones articulate at sutures (nasal bone, zygomatic bone, and maxilla) except for the mandible. The mandible articulates at the temporomandibular joint.

The location in the brain where optic nerve fibers from the temporal fields of vision cross over is identified as the

-optic chiasm. At the optic chiasm, nasal fibers (from both temporal visual fields) cross over. The fovea centralis is the area of the retina that has the sharpest and keenest vision. The optic disc is the area in which fibers from the retina converge to form the optic nerve. The choroid is the middle vascular layer of the eye; the choroid has dark pigmentation to prevent light from reflecting internally and is heavily vascularized to deliver blood to the retina.

Cerebellar function is tested by

-performance of rapid alternating movements. The cerebellum controls motor coordination of voluntary movements, equilibrium, and muscle tone. Cerebellar function is tested by balance tests (e.g., gait, Romberg test) and coordination and skilled movements (e.g., rapid alternating movements, finger-to-finger test, finger-to-nose test, heel-to-shin test). Muscle strength assessment examines the intactness of the motor system. The Phalen maneuver reproduces numbness and burning in a patient with carpal tunnel syndrome. Superficial pain and touch assessment examines intactness of the spinothalamic tract.

The extraocular muscles consist of four straight or ________ muscles and two slanting or ______ muscles.

-rectus; oblique The four straight, or rectus, muscles are the superior, inferior, lateral, and medial rectus muscles. The two slanting, or oblique, muscles are the superior and inferior muscles.

The lens of the eye functions as a

-refracting medium. The lens serves as a refracting medium, keeping a viewed object in continual focus on the retina. The muscle fibers of the iris function as the mediator of light. The cornea is very sensitive to touch. The intraocular pressure is determined by a balance between the amount of aqueous humor produced and resistance to its outflow at the angle of the anterior chamber.

Which of the following cranial nerves travels to the heart, respiratory muscles, stomach, and gallbladder

(X) Vagus Nerve

Which of the following questions would the examiner ask to determine whether an individual has epistaxis?

-"Do you experience nosebleeds?" Epistaxis is the medical term for a nosebleed. Dysphagia is the medical term for difficulty swallowing. Rhinorrhea is the medical term for a runny nose.

Which of the following statements describing a headache would warrant an immediate referral?

-"I have never had a headache like this before; it is so bad I can't function." A sudden severe headache in an adult or child who has never had it before warrants an immediate referral. A sudden severe headache could indicate a subarachnoid hemorrhage.

A slight protrusion of the eyeballs may be noticed when examining individuals who come from which ethnic/cultural group?

-African American African Americans normally may have a slight protrusion of the eyeball beyond the supraorbital ridge.

Which of the following statements r/t aggravating symptoms or triggers of headaches is true?

-Alcohol consumption may precipitate the onset of cluster or migraine headaches. Aggravating symptoms or triggers for cluster headaches include alcohol consumption, stress, or wind or heat exposure. Aggravating symptoms or triggers for migraines include hormonal fluctuations, certain foods, letdown after stress, changes in sleep pattern, sensory stimuli, and changes in weather or physical activity. Aggravating symptoms or triggers for tension headaches include stress anxiety, depression, and poor posture.

An enlarged tongue (macroglossia) may accompany:

-Down syndrome. Macroglossia occurs with Down syndrome; it also occurs with cretinism, myxedema, and acromegaly. A transient swelling also occurs with local infections.

Kyphosis of the spine is common with aging. To compensate, older adults

-Extend their heads and jaws forward. An older adult may show an increased anterior cervical (concave or inward) curve when the head and jaw are extended forward to compensate for kyphosis of the spine. shuffle.

Decreased vision in an older patient may be due to which of the following conditions?

-Macular degeneration Decreased vision in older patients is most commonly caused by cataracts, glaucoma, or macular degeneration. Retinoblastoma is a malignant tumor of the retina that usually affects children younger than 6 years old. Fixation is a reflex direction of the eye toward an object attracting a person's attention; fixation is impaired by drugs, alcohol, fatigue, and inattention. The lens in an older adult loses elasticity and becomes hard and glasslike; this decreases the lens' ability to change shape to accommodate for near vision and is called presbyopia.

What disease is characterized by a flat, expressionless, or mask like face; a staring gaze; oily skin; and elevated eyebrows?

-Parkinson disease Facial characteristics of Parkinson disease include a flat, expressionless face that is mask like with elevated eyebrows, a staring gaze, oily skin, and drooling. Facial characteristics of acromegaly include an elongated head, a massive face, a prominent nose and lower jaw, a heavy eyebrow ridge, and coarse facial features. Facial characteristics of scleroderma include hard, shiny skin on the forehead and cheeks; thin, pursed lips with radial furrowing; absent skinfolds; muscle atrophy of the face and neck; and absence of expression. Facial characteristics of Cushing syndrome include a plethoric, rounded, "moonlike" face; prominent jowls; red cheeks; and hirsutism on the upper lip, lower cheeks, and chin.

Craniosynostosis is a severe deformity caused by: 1.premature closure of the sutures. 2. increased intracranial pressure. 3. a localized bone disease that softens, thickens, and deforms bone. 4.excess growth hormone or a deficit in thyroid hormone.

-Premature closure of the sutures. Craniosynostosis is marked asymmetry that is due to a severe deformity caused by premature closure of the sutures and resulting in a long, narrow head. Hydrocephalus (obstruction of drainage of cerebrospinal fluid) results in excessive accumulation of cerebrospinal fluid, increasing intracranial pressure, and enlargement of the head. Paget disease (osteitis deformans) is a localized bone disease of unknown etiology that softens, thickens, and deforms bone. Acromegaly results from excessive secretion of growth hormone from the pituitary after puberty. Congenital hypothyroidism and myxedema are caused by thyroid hormone deficiency.

A patient is admitted to the emergency department after a motor vehicle accident. The trachea is deviated to the left side. This finding is characteristic of

-Right pneumothorax. The trachea is normally midline; with a right pneumothorax, the trachea is deviated to the unaffected side (left). The trachea is pulled downward with systole of an aortic arch aneurysm. With a large right-sided pleural adhesion, the trachea is deviated to the affected side (right). With a large right-sided atelectasis, the trachea is deviated to the affected side (right).

When inspecting the eyeballs of an African American individual, which of the following might the examiner expect to observe?

-Small brown macules on the sclera Dark-skinned people may normally have small brown macules on the sclera.

Which of the following is an expected response on the cover test?

-The covered eye maintains its position when uncovered. A normal response to the cover test is a steady fixed gaze. If muscle weakness is present, the covered eye will drift into a relaxed position. A normal response to the cover test is a steady fixed gaze. When the eye is uncovered, if it jumps to reestablish fixation, eye muscle weakness exists.

Which of the following statements regarding the results obtained from use of the Snellen chart is true?

-The larger the denominator, the poorer the vision. Using the Snellen chart, the larger the denominator, the poorer the vision.

Which of the following groups of individuals need to be tested for the presence of color blindness (deficiency)?

-White boys between the ages of 4 and 8 years Color blindness is an inherited recessive X-linked trait affecting about 8% of white boys and 4% of black boys. Test only boys for color vision once between the ages of 4 and 8 years.

During assessment of extraocular movements, two back-and-forth oscillations of the eyes in the extreme lateral gaze occur. This response indicates

-an expected movement of the eyes during this procedure. Nystagmus is a back-and-forth oscillation of the eyes. End-point nystagmus, a few beats of horizontal nystagmus at extreme lateral gaze, occurs normally.

The external structure of the ear is identified as the

-auricle. The auricle or pinna is the external structure of the ear. The atrium is the upper chamber of the heart.

The _____________ coordinates movement, maintains equilibrium, and helps maintain posture.

-cerebellum The cerebellum controls motor coordination of voluntary movements, equilibrium (i.e., posture balance of the body), and muscle tone. The extrapyramidal system maintains muscle tone and controls body movements, especially gross automatic movements such as walking. The upper motor neurons are located within the central nervous system; influence or modify the lower motor neurons; and include the corticospinal, corticobulbar, and extrapyramidal tracts. The lower motor neurons are located mostly in the peripheral nervous system and extend from the spinal cord to the muscles; examples include the cranial nerves and spinal nerves. The basal ganglia control automatic associated movements of the body.

In addition to initiating digestion of food, saliva

-cleans and protects the mucosa. Saliva moistens and lubricates the food bolus, starts digestion, and cleans and protects the mucosa.

The normal color of the optic disc is:

-creamy yellow-orange to pink. The color of a normal optic disc ranges from creamy yellow-orange to pink.

Binaural interaction at the level of the brainstem permits

-identification and location of the direction of the sound. The function at the brainstem level is binaural interaction, which permits locating the direction of a sound in space as well as identifying the sound.

A severe deficiency of thyroid hormone leading to nonpitting edema, coarse facial features, dry skin, and dry coarse hair is known as

-myxedema. Myxedema (hypothyroidism) is a deficiency of thyroid hormone. If severe, the symptoms include nonpitting edema or myxedema; a puffy edematous face, especially around the eyes (periorbital edema); coarse facial features; dry skin; and dry coarse hair and eyebrows. Congenital hypothyroidism is a thyroid deficiency that occurs at an early age; characteristics include low hairline, hirsute forehead, swollen eyelids, narrow palpebral fissures, widely spaced eyes, depressed nasal bridge, puffy face, thick tongue protruding through an open mouth, and a dull expression. Scleroderma is a rare connective tissue disease characterized by chronic hardening and shrinking degenerative changes in the skin blood vessels, synovium, and skeletal muscles. Hashimoto thyroiditis is a condition with excess thyroid hormone production; symptoms include goiter, nervousness, fatigue, weight loss, muscle cramps, heat intolerance, tachycardia, shortness of breath, excessive sweating, fine muscle tremor, thin silky hair and skin, infrequent blinking, and a staring appearance.

748. The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention should be initiated immediately?

1. Apply ice to the affected eye. Rationale: Treatment for a contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by an HCP and receive a thorough eye examination to rule out the presence of other eye injuries

What would you expect in the neuron structure in an aging adult?

1. Atrophy with loss of neuron structure in brain and spinal cord 2. Decrease in nerve conduction, making reaction time slower 3. Increased delay at synapse, diminished sense of touch,pain,taste, and smell 4. Slow motor system function, slow movement, muscle strength, and agility 5. Decrease in cerebral blood flow

752. The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply

1. Avoid activities that require bending over. 3. Take acetaminophen for minor eye discomfort. 5. Place an eye shield on the surgical eye at bedtime. 6. Contact the surgeon if a decrease in visual acuity occurs. Rationale: Following eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and usually is relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure (IOP). The nurse also would instruct the client to notify the surgeon of increased purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase IOP, such as bending over.

741. During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action?

1. Call the health care provider (HCP). Rationale: Severe pain or pain accompanied by nausea following a cataract extraction is an indicator of increased intraocular pressure and should be reported to the HCP immediately. Options 2, 3, and 4 are inappropriate actions. Test-Taking Strategy: Note the strategic word, initial, and the word severe. Eliminate option 2 because this is not a normal condition. The client should not be turned to the operative side; therefore, eliminate option 3. From the remaining options, focusing on the strategic word will direct you to the correct option

What cranial nerve test lingual speech?

1. Cranial Nerve(XII) Hypoglossal

In aging adults which of the following will cause dizziness and loss of balance?

1. Decreased cerebral blood flow

What are some occupational hazards associated with neurological impairment?

1. Exposure history 2. Medication history 3. Alcohol History 4. Substance abuse/drug abuse

What are the test conducted for cerebellar function?(balance test)

1. Gait 2. Romberg Test

What scale will assess Loss of Conscious?

1. Glasgow Coma Scale

What populations are at greater risk for strokes?

1. Hispanics 2. Blacks

751. A woman was working in her garden. She accidentally sprayed insecticide into her right eye. She calls the emergency department, frantic and screaming for help. The nurse should instruct the woman to take which immediate action?

1. Irrigate the eyes with water. Rationale: In this type of accident, the client is instructed to irrigate the eyes immediately with running water for at least 20 minutes, or until the emergency medical services personnel arrive. In the emergency department, the cleansing agent of choice is usually normal saline. Calling the HCP and going to the emergency department delays necessary intervention. Hydrogen peroxide is never placed in the eyes.

What is the correct sequence of the neurological assessment?

1. Mental Status 2. Cranial Nerves 3. Motor System 4. Sensory System 5. Reflexes

What checks for osciilation of the eyes?

1. Nystagmus

The corneal reflex?

1. Only if the patient has abnormal facial sensations or abnormalities of facial movement

What is the tool used to determine color, size, and shape of optic disk?

1. Opthalmoscope

What patient would you complete a neurological examination?

1. Patient with neurological concerns

What is the 5th most common cause of death in the United States?

1. Strokes

757. The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test?

1. The right eye is tested, followed by the left eye, and then both eyes are tested. Rationale: Visual acuity is assessed in 1 eye at a time, and then in both eyes together, with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes are then tested together. Visual acuity is measured with or without corrective lenses and the client stands at a distance of 20 feet (6 meters) from the chart.

What is a normal finding in the developmental competence in the aging adult?

1. Tremors in hands, head nodding, and tongue protrusion

What is the normal reflex response to reflex?

2+

747. A client arrives in the emergency department following an automobile crash. The client's forehead hit the steering wheel and a hyphema is diagnosed. The nurse should place the client in which position?

2. A semi-Fowler's position Rationale: A hyphema is the presence of blood in the anterior chamber. Hyphema is produced when a force is sufficient to break the integrity of the blood vessels in the eye and can be caused by direct injury, such as a penetrating injury from a BB or pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea.

756. A client with Meniere's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo?

2. Avoid sudden head movements. Rationale: The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Lying still and watching television will not control vertigo.

758. A client's vision is tested with a Snellen chart.The results of the tests are documented as 20/60. What action should the nurse implement based on this finding?

2. Instruct the client that he or she may need glasses when driving. Rationale: Vision that is 20/20 is normal—that is, the client is able to read from 20 feet (6 meters) what a person with normal vision can read from 20 feet (6 meters). A client with a visual acuity of 20/60 can only read at a distance of 20 feet (6 meters) what a person with normal vision can read at 60 feet (18 meters). With this vision, the client may need glasses while driving in order to read signs and to see far ahead. The client should be instructed to sit in the front of the room for lectures to aid in visualization. This is not considered to be legal blindness.

769. The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain? 1. Sternal rub 2. Nail bed pressure 3. Pressure on the orbital rim 4. Squeezing of the sternocleidomastoid muscle

2. Nail bed pressure Rationale: Nail bed pressure tests a basic motor and sensory peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle. Test-Taking Strategy: Focus on the subject, testing peripheral response to pain. The nail beds are the most distal of all options and are therefore the most peripheral. Each of the other options may elicit a generalized response, but not a localized one.

688. Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action? 1. Apply normal saline drops. 2. Note the time of day the test was done. 3. Contact the primary health care provider (PHCP). 4. Instruct the client to sleep with the head of the bed flat.

2. Note the time of day the test was done. Rationale: Tonometry is a method of measuring intraocular fluid pressure. Pressures between 10 and 21 mm Hg are considered within the normal range. However, IOP is slightly higher in the morning. Therefore, the initial action is to check the time the test was performed. Normal saline drops are not a specific treatment for glaucoma. It is not necessary to contact the PHCP as an initial action. Flat positions may increase the pressure.

749. A client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action?

2. Perform visual acuity tests. Rationale: If the eye injury is the result of a penetrating object, the object may be noted protruding from the eye. This object must never be removed except by the ophthalmologist because it may be holding ocular structures in place. Application of an eye patch or irrigation of the eye may disrupt the foreign body and cause further tearing of the cornea

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye?

2. Test the 6 cardinal positions of gaze

745. A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear?

2. Tinnitus Rationale: Tinnitus is the most common complaint of clients with otological disorders, especially disorders involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client's thinking process and attention span. Options 1, 3, and 4 are not associated specifically with disorders of the inner ear.

135. A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem?

3. A physical obstruction to the transmission of sound waves

133. The nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. The nurse makes this determination based on which observation? 1. An involuntary rhythmic, rapid, twitching of the eyeballs 2. A dorsiflexion of the ankle and great toe with fanning of the other toes 3. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed 4. A lack of normal sense of position when the client is unable to return extended fingers to a point of reference

3. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed

742. The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care?

3. Eye medications will need to be administered for life. Rationale: The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his or her life. Options 1, 2, and 4 are not accurate instructions.

783. A client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? 1. Giving client full control over care decisions and restricting visitors 2. Providing positive feedback and encouraging active range of motion 3. Providing information, giving positive feedback, and encouraging relaxation 4. Providing intravenously administered sedatives, reducing distractions, and limiting visitors

3. Providing information, giving positive feedback, and encouraging relaxation. Rationale: The client with Guillain-Barre syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client's condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.

759. The nurse is caring for a hearing-impaired client. Which approach will facilitate communication?

3. Speak at a normal volume. Rationale: Speaking in a normal tone to the client with impaired hearing and not shouting are important. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear.

755. The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take?

3. Speak at normal tone and pitch, slowly and clearly. Rationale: Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. When communicating with a client with this condition, the nurse should speak at a normal tone and pitch, slowly and clearly. It is not appropriate to speak loudly, mumble or slur words, or speak into the client's affected ear.

139. The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? 1. The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. 2. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. 3. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. 4. The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

3. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement?

4. "I'll try to eat my food either very warm or very cold."

744. The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe?

4. A red, dull, thick, and immobile tympanic membrane Rationale: Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane, with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head

743. The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye disorder?

4. A sense of a curtain falling across the field of vision Rationale: A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options 1 and 3 are not characteristics of this disorder. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal.

746. The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation?

4. Blurred vision Rationale: A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception. Options 1, 2, and 3 are not characteristics of a cataract.

The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery?

4. Cranial nerve VII, facial nerve

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?

4. Exhaling during repositioning

782. The client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. Which past medical history finding makes the client most at risk for this disease? 1. Meningitis or encephalitis during the last 5 years 2. Seizures or trauma to the brain within the last year 3. Back injury or trauma to the spinal cord during the last 2 years 4. Respiratory or gastrointestinal infection during the previous month

4. Respiratory or gastrointestinal infection during the previous month Rationale: Guillain-Barre syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. On occasion, the syndrome can be triggered by vaccination or surgery.

788. The nurse is admitting a client with Guillain-Barre syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? 1. Nebulizer and pulse oximeter 2. Blood pressure cuff and flashlight 3. Flashlight and incentive spirometer 4. Electrocardiographic monitoring electrodes and intubation tray

4.Electrocardiographic monitoring electrodes and intubation tray Rationale: The client with Guillain-Barre syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be available for use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the use of electrocardiographic monitoring. Because the client is immobilized, the nurse should assess for deep vein thrombosis and pulmonary embolism routinely. Although items in the incorrect options may be used in care, they are not the most essential items from the options provided.

What term is used to describe slow, twisting muscle movements that resemble a snake or worm?

Athetosis Athetosis is slow, writhing, continuous, and involuntary movements of the extremities. Ataxia is an impaired ability to coordinate movement, often characterized by a staggering gait and postural imbalance. Flaccid is weak, soft, and flabby; lacking normal muscle tone. Vestibular function is the sense of balance.

Which of the following children is at risk for recurrent otitis media (OM)?

An 18-month-old infant who has had three episodes of ear infections in a 5-month period A first episode of OM that occurs within 3 months of life increases risk for recurrent OM. Recurrent OM is three episodes within the past 3 months or four episodes within the past year.

What are abnormalities in olfactory nerve?

Anosmia(loss of smell)

Which of the following tests provides a precise quantitative measure of hearing?

Audiometer test An audiometer gives a precise quantitative measure of hearing by assessing the person's ability to hear sounds of varying frequency. The tuning fork tests (Weber and Rinne) are inaccurate and should not be used for general screening. The Romberg test assesses the ability of the vestibular apparatus in the inner ear to help maintain standing balance. The whispered voice test is nonquantitative; this test documents the presence of hearing loss but does not measure the degree of loss.

Which of the following behaviors demonstrated by an individual may be indicative of hearing loss?

Frequently asking for the question to be repeated Hearing loss is indicated when a person frequently asks to have statements repeated. Hearing loss is indicated when a person lip reads or watches faces and lips closely. Hearing loss is indicated when a person has a flat, monotonous tone of voice. Hearing loss is indicated when speech sounds are garbled, vowel sounds are distorted, and the person uses an inappropriately loud voice.

Which of the following pairs of sinuses is absent at birth, is fairly well developed between 7 and 8 years of age, and is fully developed after puberty?

Frontal The frontal sinuses are absent at birth, are fairly well developed between 7 and 8 years of age, and reach full size after puberty. The maxillary sinuses are present at birth and reach full size after all permanent teeth have erupted. The sphenoid sinuses are minute at birth and develop after puberty. The ethmoid sinuses are present at birth and grow rapidly between 6 and 8 years of age and after puberty.

The examiner notices a fine tremor when the patient sticks out his or her tongue. What disorder is consistent with this finding?

Hyperthyroidism A fine tremor of the tongue occurs with hyperthyroidism. A patient in diabetic ketoacidosis would have a sweet, fruity breath odor. Halitosis is a term used to describe any breath odor. A coarse tremor occurs with alcoholism.

On examination of the mouth of an American Indian, the examiner notices the presence of a bifid uvula. How should this finding be interpreted?

This is an expected variation associated with this individual. Bifid uvula is a condition in which the uvula is split either completely or partially. This condition occurs in 18% of individuals in some American Indian groups. Bifid uvula may indicate a submucous cleft palate. Bifid uvula is not associated with oral cancer. The incidence of bifid uvula is common in American Indians.

What is the major cause of decreased saliva production in older adults?

Use of anticholinergic medications. The major cause of decreased saliva flow is the use of medications that have anticholinergic effects. Normal aging is a secondary cause of decreased saliva flow. Decreased fluid intake is not the major cause of decreased saliva production in an older adult. Diminished sense of taste and smell associated with aging may decrease an older adult's interest in food and may contribute to malnutrition.

The extrapyramidal system is located in the

basal ganglia The basal ganglia are large bands of gray matter buried deep within the two cerebral hemispheres that form the subcortical associated motor system (the extrapyramidal system).

The nasal mucosa of an individual with rhinitis would be

bright red and swollen. The nasal mucosa is bright red and swollen with rhinitis. Normally, the nasal mucosa is red with a smooth and moist surface. The nasal mucosa is swollen, boggy, pale, and gray with chronic allergies. Bright red bleeding occurs with epistaxis (bleeding from the nose).

The labyrinth of the inner ear is responsible for maintaining the body's

equilibrium. The labyrinth maintains the body's equilibrium. Binaural interaction is controlled by the brainstem and permits locating the direction of a sound. The normal pathway of hearing is by air conduction. The eustachian tube allows equalization of air pressure on each side of the tympanic membrane.

Do not place a client with a head injury in a ______________ or ___________ position because of the risk of increased intracranial pressure.

flat or Trendelenburg's

The position of the tympanic membrane in the neonate is more ________________, making it more difficult to visualize with the otoscope.

horizontal The position of the eardrum is more horizontal in the neonate, making it more difficult to see completely and harder to differentiate from the canal wall. By 1 month of age, the eardrum is in the oblique position similar to an older child, and examination is easier.

The presence of primitive reflexes in a newborn infant is indicative of

immaturity of the nervous system. The nervous system is not completely developed at birth, and motor activity in the newborn is under the control of the spinal cord and medulla. The neurons are not yet myelinated. Movements are directed primarily by primitive reflexes. As the cerebral cortex develops during the first year, it inhibits these reflexes, and they disappear at predictable times. Persistence of the primitive reflexes is an indication of central nervous system dysfunction.

One of the purposes of the paranasal sinuses is to

lighten the weight of the skull bones. The paranasal sinuses lighten the weight of the skull bones. Nasal mucosa and nasal turbinates warm, humidify, and filter the inhaled air. The paranasal sinuses serve as resonators for sound production. Olfactory receptors (responsible for the sensation of smell) are located in the nasal cavity and septum and merge into the olfactory nerve.

An abnormal sensation of burning or tingling is best described as

paresthesia. Paresthesia is an abnormal sensation such as burning or tingling. Paralysis is a loss of motor function as a result of a lesion in the neurologic or muscular system or loss of sensory innervation. Paresis is a partial or incomplete paralysis. Paraphasia is a condition in which a person hears and comprehends words but is unable to speak correctly; incoherent words are substituted for intended words.

Testing the deep tendon reflexes gives the examiner information regarding the intactness of the

reflex arc at specific levels in the spinal cord. Measurement of the deep tendon reflexes reveals the intactness of the reflex arc at specific spinal levels. The corticospinal tract is the higher motor system that permits very skilled and purposeful movements such as writing. The medulla contains all ascending and descending fiber tracts; it has vital autonomic centers for respiration, heart, and gastrointestinal function as well as nuclei for cranial nerves VIII through XII. The upper motor neurons are located within the central nervous system and influence or modify the lower motor neurons and include the corticospinal, corticobulbar, and extrapyramidal tracts. The lower motor neurons are located mostly in the peripheral nervous system and extend from the spinal cord to the muscles; examples include the cranial nerves and spinal nerves.

If the tympanic membrane has white dense areas, the examiner suspects

scarring from recurrent ear infections. White dense areas indicate scarring on the tympanic membrane from recurrent ear infections. Dark oval areas indicate perforation from a ruptured tympanic membrane. Air or fluid levels or air bubbles indicate serous fluid from serous otitis media. Black or white dots indicate a fungal infection.

Clonus that may be seen when testing deep tendon reflexes is characterized by a(n)

set of rapid, rhythmic contractions of the same muscle. Clonus is a set of rapid, rhythmic contractions of the same muscle.

The duct in the parotid gland that opens into the mouth opposite the second molar is

the Stensen duct. The duct in the parotid gland is the Stensen duct; it runs forward to open on the buccal mucosa opposite the second molar. The Wharton's duct (for the submandibular gland) runs up and forward to the floor of the mouth and opens at either side of the frenulum. The mouth contains three pairs of salivary glands, which are the parotid gland, the submandibular gland, and the sublingual gland. The sublingual gland lies within the floor of the mouth under the tongue.

Automatic associated movements of the body are under the control and regulation of

the basal ganglia. The basal ganglia controls automatic associated movements of the body. The thalamus is where sensory pathways of the spinal cord, cerebellum, and brainstem form synapses on their way to the cerebral cortex. The hypothalamus is a major respiratory center with basic vital functions: temperature, appetite, sex drive, heart rate, and blood pressure control; sleep center; anterior and posterior pituitary gland regulation; and coordination of autonomic nervous system activity and stress response. Wernicke's area in the temporal lobe is associated with language comprehension.

When an otoscopic examination is performed on an older adult patient, the tympanic membrane may be

whiter than that of a younger adult. During otoscopy, the tympanic membrane of an older adult may be whiter in color than that of a younger adult. The tympanic membrane may also appear more opaque and dull. A yellow-amber eardrum color occurs with otitis media with effusion. A red color occurs with acute otitis media. The tympanic membrane of an older adult may be thicker compared with that of a younger adult. Hypomobility is an early sign of acute otitis media.