A nurse is assessing cranial nerve VIII.
What tests will be administered on the client?
Whisper and Romberg tests.
PERRLA and EOMs.
Snellen and Rosenbaum tests.
Rinne and Weber tests.
The Correct Answer is D
Choice A rationale
The Whisper test evaluates hearing acuity, while the Romberg test assesses balance and proprioception by having the client stand with feet together and eyes closed. Both tests involve sensory assessments but do not directly assess cranial nerve VIII, which is the vestibulocochlear nerve responsible for hearing and balance.
Choice B rationale
PERRLA (pupils equal, round, reactive to light and accommodation) assesses cranial nerves II and III, while EOMs (extraocular movements) assess cranial nerves III, IV, and VI. These tests do not evaluate cranial nerve VIII.
Choice C rationale
Snellen and Rosenbaum tests measure visual acuity for distance and near vision, respectively. These tests assess cranial nerves II and III but do not evaluate cranial nerve VIII.
Choice D rationale
The Rinne and Weber tests are audiometric assessments that specifically evaluate cranial nerve VIII, which controls hearing and balance. The Rinne test compares air and bone conduction of sound, while the Weber test assesses sound lateralization, making them appropriate tests for assessing cranial nerve VIII.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Fibrocystic lesions in the breast are benign changes that involve the formation of cysts and fibrous tissue. These do not typically cause an orange-peel appearance of the skin.
Choice B rationale
A normal finding of the breast would not include an orange-peel or "peau d'orange" appearance, as this is considered an abnormal change often associated with underlying pathology.
Choice C rationale
Carcinoma of the breast can lead to an orange-peel appearance of the skin due to lymphatic obstruction. This dimpling effect is caused by the cancerous infiltration and thickening of the skin, making this the correct answer.
Choice D rationale
Fibroadenoma is a benign tumor of the breast and does not usually cause the skin changes described as orange-peel appearance. This condition is generally not associated with skin texture changes.
Correct Answer is C
Explanation
Choice A rationale
Functional incontinence occurs when an individual cannot reach the bathroom in time due to physical or cognitive limitations. It is not related to stress or pressure on the bladder but rather to external factors that impede timely access to toileting facilities.
Choice B rationale
Reflex incontinence is characterized by involuntary loss of urine due to a lack of signal awareness or detrusor muscle overactivity. It is typically associated with neurological conditions such as spinal cord injuries or multiple sclerosis. This type of incontinence does not involve stress-related triggers like coughing or sneezing.
Choice C rationale
Stress incontinence involves the involuntary leakage of urine during activities that increase intra-abdominal pressure, such as coughing, sneezing, laughing, or physical exertion. This type of incontinence is commonly seen in women, particularly after childbirth or during menopause, due to weakened pelvic floor muscles or sphincter dysfunction.
Choice D rationale
Urge incontinence is characterized by a sudden and intense urge to urinate, often resulting in involuntary urine leakage before reaching the bathroom. It is typically caused by overactive bladder muscles or nerve signals and is not specifically triggered by actions like coughing or sneezing.
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