A nurse is assessing a client’s cranial nerve VII. Which of the following responses should the nurse expect?

The client has a symmetrical smile.

The client’s tongue is in a midline position.

The client turns their head against resistance.

The client’s pupils constrict in response to light.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Cranial nerve VII, also known as the facial nerve, is responsible for controlling the muscles of facial expression. When assessing this nerve, a nurse would expect to see symmetrical facial movements, such as a symmetrical smile. This indicates that the facial nerve is functioning properly on both sides of the face. Any asymmetry could suggest a problem with the facial nerve, such as Bell’s palsy or a stroke.

Choice B Reason:

The position of the tongue is controlled by cranial nerve XII, the hypoglossal nerve, not cranial nerve VII. The hypoglossal nerve is responsible for the movements of the tongue, and a midline position indicates normal function of this nerve. Therefore, this response is not relevant to the assessment of cranial nerve VII.

Choice C Reason:

Turning the head against resistance is a test for cranial nerve XI, the accessory nerve. This nerve controls the sternocleidomastoid and trapezius muscles, which are involved in head and shoulder movements. Assessing the ability to turn the head against resistance helps evaluate the function of the accessory nerve, not the facial nerve.

Choice D Reason:

Pupillary constriction in response to light is a function of cranial nerve III, the oculomotor nerve. This nerve controls the muscles that constrict the pupil in response to light, a reflex known as the pupillary light reflex. This response is not related to the function of cranial nerve VII.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A Reason: Have a padded tongue blade available at the client’s bedside.

Having a padded tongue blade available is not recommended for seizure management. Inserting any object into a patient’s mouth during a seizure can cause injury to the teeth, gums, or jaw1. Current guidelines advise against placing anything in the mouth of a person having a seizure. Instead, focus on ensuring the patient’s safety by turning them on their side to maintain an open airway and prevent aspiration.

Choice B Reason: Keep the four side rails down when the client is in bed.

Keeping the side rails down is not advisable for a client with a seizure disorder. To prevent injury during a seizure, it is important to keep the side rails up and padded. This helps prevent the client from falling out of bed and sustaining injuries. Additionally, the bed should be kept in its lowest position to minimize the risk of injury from falls.

Choice C Reason: Keep suction equipment available in the client’s room.

Keeping suction equipment available is crucial for managing a client with a seizure disorder. During a seizure, there is a risk of aspiration due to excessive salivation or vomiting. Having suction equipment readily available allows the nurse to quickly clear the client’s airway, reducing the risk of aspiration and ensuring the client can breathe properly1.

Choice D Reason: Have wire cutters available at the client’s bedside.

Wire cutters are not typically necessary for managing a seizure disorder. They are sometimes mentioned in the context of clients with Vagus Nerve Stimulators (VNS), where the wire cutters might be used in an emergency to cut the VNS wire. However, this is a rare situation and not a standard precaution for all clients with seizure disorders4.

A. “Use a size 20 French catheter for catheterization.” B. “Allow the drainage bag to fill completely before emptying.” C. “Disconnect the drainage tube if the catheter requires irrigation.” D. “Keep the collection bag below bladder level.”

Correct Answer is C

Explanation

Choice A reason:

“Use a size 20 French catheter for catheterization.” This statement is incorrect. Using a larger catheter size, such as 20 French, can increase the risk of trauma and infection. It is generally recommended to use the smallest catheter size possible to minimize the risk of catheter-associated urinary tract infections (CAUTIs) and other complications.

Choice B reason:

“Allow the drainage bag to fill completely before emptying.” This statement is incorrect. Allowing the drainage bag to fill completely can increase the risk of infection and cause backflow of urine into the bladder. It is recommended to empty the drainage bag when it is two-thirds full to prevent these issues.

Choice C reason:

“Disconnect the drainage tube if the catheter requires irrigation.” This statement is incorrect. Disconnecting the drainage tube can break the closed system and increase the risk of infection. If irrigation is necessary, it should be done using a closed system to maintain sterility and reduce the risk of CAUTIs.

Choice D reason:

“Keep the collection bag below bladder level.” This statement is correct. Keeping the collection bag below bladder level helps prevent backflow of urine into the bladder, which can reduce the risk of infection. This practice is a key component of preventing CAUTIs and is recommended in clinical guidelines.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assessing a client’s cranial nerve VII. Which of the following responses should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a seizure disorder. Which of the following actions should the nurse include in the client’s plan of care?

Correct Answer is C

Explanation

A charge nurse is teaching a group of nurses about decreasing the risk for catheter-associated urinary tract infections in clients. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is teaching a group of older adult clients about medication safety. Which of the following client statements indicates an understanding of the teaching?

A nurse is preparing to transfer a client to the radiology department using a wheelchair. Which of the following actions should the nurse take?

A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?

A home health nurse is providing teaching about home safety to an older adult client. Which of the following examples of home safety should the nurse include in the teaching?

A nurse is obtaining a specimen for a wound culture from a client. Which of the following actions should the nurse take?

A nurse is assessing a client’s cranial nerve VII. Which of the following responses should the nurse expect?

A nurse is teaching a client about stress management techniques. Which of the following client statements indicates an understanding of the teaching?

A nurse is assessing a client whose partner is receiving hospice care and is dying. The client states, “I should start planning the trip that we want to take.” Which of the following ego-defense mechanisms is the client expressing?