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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 A

Explanation

Choice A reason: Starting chest compressions is the priority intervention for a client who is unresponsive, not breathing, and without a pulse. This situation indicates cardiac arrest, and immediate chest compressions are crucial to maintain circulation and oxygen delivery to vital organs. Early initiation of chest compressions improves the chances of survival and neurological outcomes.

Choice B reason: Obtaining a central line is not an immediate priority in the context of cardiac arrest. While central lines are important for administering medications and fluids, the first step in resuscitation is to establish effective chest compressions. Central line placement can be considered after initial resuscitation efforts are underway.

Choice C reason: Completing a comprehensive assessment is important, but it is not the immediate priority in a cardiac arrest situation. The primary focus should be on initiating chest compressions and basic life support measures. A detailed assessment can be performed once the client is stabilized.

Choice D reason: Providing rescue breathing is part of cardiopulmonary resuscitation (CPR), but it should follow the initiation of chest compressions. Current guidelines emphasize the importance of starting chest compressions immediately and then integrating rescue breaths. Effective chest compressions are the foundation of CPR.

A. Prolonging the life of a client. B. Controlling symptoms and providing comfort. C. Replacing other treatments for an illness. D. Curing a serious illness.

Correct Answer is B

Explanation

Choice A Reason:

Prolonging the life of a client is not the primary focus of palliative care. While palliative care can sometimes extend life by improving overall well-being and reducing stress, its main goal is to enhance the quality of life by managing symptoms and providing comfort12. Palliative care is not primarily aimed at life extension but rather at ensuring that patients live as well as possible despite their illness.

Choice B Reason:

Controlling symptoms and providing comfort is the core focus of palliative care. This type of care aims to alleviate pain and other distressing symptoms, such as nausea, shortness of breath, and fatigue12. Palliative care also addresses emotional, social, and spiritual needs, helping patients and their families cope with the challenges of serious illness. By focusing on comfort and quality of life, palliative care supports patients in living as fully as possible.

Choice C Reason:

Replacing other treatments for an illness is not the focus of palliative care. Palliative care is designed to complement, not replace, other medical treatments12. It can be provided alongside curative or life-prolonging treatments, offering additional support to manage symptoms and improve quality of life. The goal is to provide a holistic approach to care that addresses all aspects of a patient’s well-being.

Choice D Reason:

Curing a serious illness is not the aim of palliative care. Palliative care is appropriate for patients at any stage of a serious illness, whether or not a cure is possible12. Its primary focus is on symptom management, comfort, and quality of life, rather than on curing the illness. This approach helps patients and their families navigate the complexities of serious health conditions with greater ease and support.

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

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Naxlex Comprehensive Predictor Exams

A nurse is doing hourly rounding and finds a client unresponsive. The nurse is unable to obtain a pulse and the client is not breathing. What intervention would be the priority for this client?

Correct Answer is A

Explanation

A nurse is teaching a class about palliative care. The nurse should include that which of the following is the focus of palliative care?

Correct Answer is B

Explanation

A nurse is assessing a client who is receiving a unit of packed RBCs. The client appears flushed and reports low-back pain. After stopping the transfusion, which intervention is important to complete FIRST?

The nurse is caring for a newborn requiring a life-saving blood transfusion. The parents are practicing Jehovah’s Witnesses and refuse the transfusion. Who would the nurse consult for assistance in this situation?

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