A 54 year-old client diagnosed with Bipolar disorder is clenching his jaw closed to avoid taking a prescribed oral medication. The nurse can use this observation to confirm the client is demonstrating motor function of which cranial nerve?

Vagus

Facial

Glossopharygeal

Trigeminal

Answer and Explanation

The Correct Answer is D

A. Vagus: The vagus nerve (cranial nerve X) is involved in regulating autonomic functions, such as heart rate and digestion. It does not play a significant role in controlling jaw movements or clenching.
B. Facial: The facial nerve (cranial nerve VII) controls facial expressions, such as smiling or frowning, and also contributes to taste sensation in the anterior two-thirds of the tongue. While it is related to facial motor function, it does not control the jaw muscles responsible for clenching.
C. Glossopharyngeal: The glossopharyngeal nerve (cranial nerve IX) is involved in taste sensation on the posterior one-third of the tongue, as well as in swallowing and salivation. It does not control the jaw muscles used for clenching.
D. Trigeminal: The trigeminal nerve (cranial nerve V) is responsible for sensation in the face and motor functions related to chewing. It innervates the muscles of mastication, including those involved in clenching the jaw. The client’s jaw clenching is a direct manifestation of motor function associated with the trigeminal nerve.

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Correct Answer is A

Explanation

A) This is an abnormal breath sound due to bronchial airways being narrowed, bronchoconstriction: Wheezing is an abnormal breath sound characterized by a high-pitched whistling noise produced during breathing. It occurs when the bronchial airways are narrowed due to bronchoconstriction, inflammation, or mucus, common in conditions like asthma. This narrowing of the airways creates turbulent airflow, leading to the wheezing sound.

B) This is a normal breath sound due to normal gas exchange: Wheezing is not a normal breath sound and is indicative of an obstruction or narrowing in the airways. Normal breath sounds, such as vesicular breath sounds, are smooth and do not include wheezing.

C) This is an abnormal breath sound due to bronchial airways being dilated, bronchodilation: Wheezing results from airway narrowing, not dilation. Bronchodilation, which is the widening of the airways, would typically reduce or resolve wheezing rather than cause it.

D) This is a normal breath sound due to the alveoli being fluid-filled: Wheezing is related to airway narrowing rather than fluid in the alveoli. Fluid in the alveoli would more commonly cause crackles or rales, not wheezing.

A. Obtunded B. Stupor C. Coma D. Lethargy

Correct Answer is C

Explanation

A. Obtunded: Obtunded describes a state where a person has reduced alertness and is difficult to arouse but can respond to stimuli, such as verbal commands or physical touch. The client’s eyes remain closed and they are unresponsive to all stimuli, which is more severe than obtunded.
B. Stupor: Stupor is a condition where a person is in a near-unconscious state and responds only to vigorous or painful stimuli. Although the client is unresponsive to all stimuli, stupor usually involves some minimal response to pain or other strong stimuli, which doesn’t match the complete unresponsiveness described.
C. Coma: A coma is a profound state of unconsciousness where a person is unresponsive to all stimuli, including verbal, visual, and painful stimuli, and their eyes remain closed. This description matches the client’s condition of being unresponsive and with closed eyes.
D. Lethargy: Lethargy is characterized by excessive drowsiness or a reduced level of consciousness where the individual can be aroused with minimal effort. This state does not accurately describe a client who is unresponsive to all stimuli and whose eyes remain closed.

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A 54 year-old client diagnosed with Bipolar disorder is clenching his jaw closed to avoid taking a prescribed oral medication. The nurse can use this observation to confirm the client is demonstrating motor function of which cranial nerve?

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Explanation

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