During the taking of the health history of a 78-year-old man, his ...

[kshipps]

During the taking of the health history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: He can't even remember how to button his shirt.
 
  When assessing his sensory system, which action by the nurse is most appropriate?
  a.
  The nurse would not test the sensory system as part of the examination because the results would not be valid.
  b.
  The nurse would perform the tests, knowing that mental status does not affect sensory ability.
  c.
  The nurse would proceed with an explanation of each test, making certain that the wife understands.
  d.
  Before testing, the nurse would assess the patient's mental status and ability to follow directions.

Question 2

The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of always dropping things and falling down. While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees.
 
  Her response is extremely slow and she frequently misses. What should the nurse suspect?
  a.
  Vestibular disease
  b.
  Lesion of CN IX
  c.
  Dysfunction of the cerebellum
  d.
  Inability to understand directions

[elyse44]

Answer to Question 1

ANS: D
The nurse should ensure the validity of the sensory system testing by making certain that the patient is alert, cooperative, comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading and invalid results.

Answer to Question 2

ANS: C
When a person tries to perform rapid, alternating movements, responses that are slow, clumsy, and sloppy are indicative of cerebellar disease. The other responses are incorrect.

[kshipps]

TYSM

[jomama]

Gracias!