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.

Answer and Explanation

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.

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Correct Answer is ["B","E"]

Explanation

Choice A rationale

Patches of eschar covering parts of the wound are characteristic of more advanced pressure ulcers, such as Stage III or IV, where necrotic tissue is present. Eschar is a dark, thick, leathery scab or crust that indicates deeper tissue damage and is not observed in Stage II pressure ulcers.

Choice B rationale

A Stage II pressure ulcer is characterized by partial thickness skin erosion with loss of the epidermis and dermis. It appears as a shallow open ulcer with a red-pink wound bed, indicating that the damage has not extended beyond these layers of skin.

Choice C rationale

When a pressure ulcer extends into the subcutaneous tissue, it is classified as a Stage III or IV ulcer, depending on the depth and extent of tissue involvement. Stage II ulcers are limited to the epidermis and dermis and do not reach the subcutaneous layer.

Choice D rationale

Intact skin that appears red but is not broken is indicative of a Stage I pressure ulcer, which represents the earliest stage of pressure injury. Stage I ulcers involve non-blanchable erythema (redness) but no open wound or skin erosion.

Choice E rationale

Open blister areas with a red-pink wound bed are characteristic of Stage II pressure ulcers. These ulcers exhibit partial thickness skin loss and can present as open or fluid-filled blisters with a visible wound bed.

Choice F rationale

Localized redness in light skin that blanches with fingertip pressure is typical of a Stage I pressure ulcer. Blanching erythema indicates that the skin is still viable and blood flow is present, which differentiates Stage I from more advanced stages of pressure injury.

A. Leukoplakia. B. Gingival hyperplasia. C. Gingivitis. D. Periodontitis.

Correct Answer is C

Explanation

Choice A rationale

Leukoplakia refers to white patches or plaques that develop on the mucous membranes of the oral cavity. It is usually seen as a precancerous condition and is associated with chronic irritation, smoking, or other risk factors. These white patches are not typically associated with redness and bleeding of the gums.

Choice B rationale

Gingival hyperplasia involves the overgrowth or enlargement of the gums. It can be due to various factors, including medications (such as anticonvulsants or calcium channel blockers), hormonal changes, or certain systemic conditions. While the gums may appear enlarged and possibly bleed, gingival hyperplasia is not characterized by redness and bleeding as primary symptoms.

Choice C rationale

Gingivitis is the inflammation of the gums (gingiva) and is characterized by redness, swelling, and bleeding. It is usually caused by plaque buildup along the gumline, leading to irritation and inflammation. Gingivitis is considered an early stage of gum disease and can be reversed with proper oral hygiene and dental care.

Choice D rationale

Periodontitis is an advanced stage of gum disease that occurs when gingivitis is left untreated. It involves the destruction of the supporting structures of the teeth, including the alveolar bone and periodontal ligaments. Symptoms of periodontitis include gum recession, pockets forming between the gums and teeth, and possible tooth loss. While periodontitis can lead to bleeding gums, it is more severe than the initial symptoms of redness and bleeding seen in gingivitis.

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A nurse is assessing cranial nerve VIII.What tests will be administered on the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has been admitted to the hospital after the staff at a nursing home noticed a pressure ulcer on his sacral area.The nurse examines the sacral ulcer and determines it is a Stage II ulcer.Which of these findings is characteristic of a Stage II pressure ulcer?

Correct Answer is ["B","E"]

Explanation

The nurse is inspecting the gums on a patient and notices redness and bleeding.Which unexpected finding is present?

Correct Answer is C

Explanation

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A nurse is assessing cranial nerve VIII.
What tests will be administered on the client?