A nurse is assessing a client's cranial nerves. Which method should the nurse use to assess cranial nerve I?

Ask the client to identify scented aromas.

Ask the click to read a Snellen chart.

Listen to the client's speech.

Ask the client to clench his teeth.

Answer and Explanation

The Correct Answer is A

A. Asking the client to identify scented aromas assesses cranial nerve I (olfactory nerve), which is responsible for the sense of smell.
B. Reading a Snellen chart assesses cranial nerve II (optic nerve), which is related to vision.
C. Listening to the client's speech evaluates the function of cranial nerves V (trigeminal) and XII (hypoglossal), which are related to mastication and tongue movement, respectively.
D. Asking the client to clench his teeth tests cranial nerve V, which innervates the muscles of mastication.

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Correct Answer is B

Explanation

A. The planning phase involves setting goals and determining interventions based on the assessment data.

B. The assessment phase is where the nurse gathers information about the client's health history, including potential allergies, which is essential for safe care and diagnostic testing.

C. The implementation phase involves carrying out the planned interventions, which would include considerations for allergies but not the initial questioning about them.

D. The evaluation phase assesses the effectiveness of the interventions and the client's response to care, which is not the appropriate time to inquire about allergies.

A. Severe pitting, very swollen leg and indentation that lasts for a long time, 8 mm deep B. Slight indentation, with no perceptible swelling of the leg. 2 mm deep C. Moderate pitting, with indentation that subsides rapidly, 4 mm deep D. Deep pitting, swollen leg, and indentation that remains for a short time, 6 mm deep

Correct Answer is A

Explanation

A. +4 pitting edema is characterized by severe pitting that creates a deep indentation (greater than 8 mm) that remains for a prolonged period. This description matches the findings in option A.

B. This describes +1 pitting edema, which is not consistent with +4 edema.

C. This option describes +2 or +3 pitting edema, as the indentation subsides rapidly, which does not align with +4.

D. Although this describes deep pitting, the depth is less than 8 mm, which is not consistent with +4 edema.

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A nurse is assessing a client's cranial nerves. Which method should the nurse use to assess cranial nerve I?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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