A nurse is assessing a client’s cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II?

Listen to the client’s speech

Ask the client to identify scented aromas

Ask the client to clench his teeth

Ask the client to read a Snellen chart

Answer and Explanation

The Correct Answer is D

Choice A rationale: Listening to the client's speech is not related to the assessment of cranial nerve II.

Choice B rationale: Assessing the ability to identify scented aromas is more related to cranial nerve I (olfactory nerve).

Choice C rationale: Asking the client to clench their teeth is related to the assessment of cranial nerve V (trigeminal nerve).

Choice D rationale: Cranial nerve II, the optic nerve, is responsible for vision. The nurse should use the Snellen chart to assess visual acuity.

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Correct Answer is D

Explanation

Choice A rationale: A peritoneal friction rub is a grating sound caused by the movement of inflamed peritoneal surfaces and is not associated with bowel sounds.

Choice B rationale: Loud continual humming bowel sounds do not accurately describe borborygmi and are not a common term used to describe bowel sounds.

Choice C rationale: Hypoactive bowel sounds indicate decreased bowel motility and are not associated with borborygmi.

Choice D rationale: Borborygmi refers to loud, gurgling bowel sounds that are audible without the use of a stethoscope. It is a normal sound associated with the movement of gas and fluid through the intestines.

A. Asymmetry with one side hanging lower than the other B. Marked tenderness on palpation C. Easy sliding of scrotal contents when palpated D. Presence of small, firm, nontender, yellowish nodules

Correct Answer is B

Explanation

Choice A rationale: Asymmetry with one side hanging lower than the other is a normal variation in scrotal anatomy.

Choice B rationale: Marked tenderness on palpation of the scrotum is abnormal and may indicate inflammation or infection.

Choice C rationale: Easy sliding of scrotal contents when palpated is a normal finding.

Choice D rationale: Small, firm, nontender, yellowish nodules may represent sebaceous cysts or Fordyce spots, which are typically benign and not a cause for concern.

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A nurse is assessing a client’s cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

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