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 A
Explanation
Choice A rationale
"C" in the ABCDE criteria for assessing skin lesions stands for Color. This criterion refers to the variations in the color of the lesion, which could include shades of black, brown, tan, or even white, red, or blue. Uneven or multiple colors within a single lesion can be a warning sign of melanoma, a type of skin cancer. Regularly checking the color of moles or spots on the skin is crucial for early detection of potential malignancies.
Choice B rationale
Characteristics are not part of the ABCDE criteria. The ABCDE criteria specifically stand for Asymmetry, Border, Color, Diameter, and Evolving. These criteria are used by healthcare professionals to identify suspicious skin lesions that may need further evaluation or biopsy to rule out skin cancer. Focusing on these specific aspects helps in early detection and treatment of malignant skin conditions.
Choice C rationale
Crepitus is a term used to describe a crackling or grating sound or sensation, typically associated with bones or joints, and is not related to skin lesion assessment. Crepitus can be felt or heard in conditions such as arthritis, where the cartilage in the joints has worn away, causing bones to rub against each other. It is unrelated to the ABCDE criteria for skin lesions.
Choice D rationale
Coping methods are strategies used by individuals to manage stress, emotions, or adverse situations and have no relevance to the ABCDE criteria for skin lesions. Coping methods can include techniques like exercise, meditation, or talking to a therapist, but they do not pertain to the physical examination of skin lesions for signs of cancer.
Correct Answer is A
Explanation
Choice A rationale
The general survey is an overall assessment of a client's physical appearance, behavior, mobility, and neurological status. It provides a comprehensive overview of the client's health and well-being, making it the focus of the nurse's observations in this scenario.
Choice B rationale
Medical history includes past and current health conditions, surgeries, medications, and family health history. While important, it is not the focus of the nurse's immediate observations in this scenario.
Choice C rationale
Biographical data involves personal information such as age, gender, occupation, and marital status. While relevant to the client's health, it is not the primary focus of the nurse's observations in this scenario.
Choice D rationale
Social history includes information about the client's lifestyle, habits, and social environment. While valuable for understanding the client's overall health context, it is not the focus of the nurse's immediate observations in this scenario. .
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