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

A nurse is educating a client about supplements that are effective for nausea. Which supplement should the nurse include?

Ask the client to clench their teeth.

Ask the client to read a Snellen chart.

Ask the client to raise his eyebrows.

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Listening to the client’s speech is not a method used to assess cranial nerve V. This method is more relevant for assessing cranial nerves IX (Glossopharyngeal) and X (Vagus), which are involved in speech and swallowing.

Choice B Reason:

Clenching the teeth is a method used to assess the motor function of cranial nerve V (the trigeminal nerve). The trigeminal nerve is responsible for the movement of the muscles involved in chewing. When a client clenches their teeth, the nurse can palpate the masseter and temporal muscles to check for strength and symmetry. This helps determine if there are any abnormalities in the motor function of the trigeminal nerve.

Choice C Reason:

Asking the client to read a Snellen chart is a method used to assess cranial nerve II (Optic), which is responsible for vision. This method does not assess cranial nerve V.

Choice D Reason:

Asking the client to raise his eyebrows is a method used to assess cranial nerve VII (Facial), which controls facial expressions. This method is not used to assess cranial nerve V.

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Correct Answer is D

Explanation

Choice A Reason:

Sleep deprivation is incorrect. While sleep deprivation can cause confusion and disorientation, it is less likely to cause abrupt onset of altered mental status and hallucinations. Sleep deprivation typically results in gradual cognitive decline and fatigue rather than sudden changes.

Choice B Reason:

Normal signs of aging is incorrect. Normal aging can involve some cognitive decline, but it does not typically cause sudden and severe symptoms like hallucinations and significant disorientation. These symptoms are more indicative of an acute condition.

Choice C Reason:

Dementia is incorrect. Dementia involves a gradual decline in cognitive function over time and does not typically present with sudden onset of symptoms. While dementia can include hallucinations and disorientation, these symptoms usually develop progressively.

Choice D Reason:

Delirium is correct. Delirium is characterized by a sudden onset of confusion, disorientation, and changes in mental status. It is often triggered by acute medical conditions such as infections, including UTIs. Elderly patients are particularly susceptible to delirium, which can include symptoms like hallucinations and severe confusion.

A. Hyperkalosis B. Hyponatremia C. Acidosis D. Alkalosis

Correct Answer is C

Explanation

Choice A Reason:

Hyperkalosis is incorrect. Hyperkalosis refers to an elevated level of potassium in the blood, which is not directly related to the pH level. While hyperkalemia can occur in acidosis, it is not the primary condition indicated by a low pH

Choice B Reason:

Hyponatremia is incorrect. Hyponatremia refers to low sodium levels in the blood. It does not directly affect the pH level and is not indicated by the pH value provided.

Choice C Reason:

Acidosis is correct. The normal pH range for arterial blood is 7.35 to 7.45. A pH of 7.10 is below this range, indicating that the blood is too acidic. This condition is known as acidosis.

Choice D Reason:

Alkalosis is incorrect. Alkalosis refers to a condition where the blood pH is higher than the normal range, indicating that the blood is too basic. A pH of 7.10 is too low, not too high, and therefore indicates acidosis.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an elderly client diagnosed with a urinary tract infection (UTI). The family reports an abrupt onset of altered mental status, disorientation, and intermittent hallucinations. The nurse would identify these signs to be consistent with which sensory alteration?

Correct Answer is D

Explanation

A nurse is caring for a client who had an arterial blood gas drawn. The pH on the ABG is 7.10. What acid-base imbalance does this client have?

Correct Answer is C

Explanation

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