A nurse is auscultating heart sounds on a client and hears an extra sound late in diastole, just before the S1. How should the nurse document this finding?

A) II:
This is the correct answer. The optic nerve (cranial nerve II) is responsible for visual acuity, as it transmits visual information from the retina to the brain. When assessing visual acuity, the nurse is evaluating the function of the optic nerve, which is responsible for the sense of vision. Therefore, cranial nerve II should be assessed during a visual acuity exam.

B) I:
This is incorrect. The olfactory nerve (cranial nerve I) is responsible for the sense of smell, not vision. Visual acuity is not related to the olfactory nerve, so it is not involved in this type of assessment.

C) VI:
This is incorrect. The abducens nerve (cranial nerve VI) controls the lateral rectus muscle of the eye, which is responsible for outward eye movement. While cranial nerve VI plays a role in eye movement, it is not directly involved in measuring visual acuity, which pertains to the function of the optic nerve.

D) IV:
This is incorrect. The trochlear nerve (cranial nerve IV) controls the superior oblique muscle, which helps with eye movement, specifically downward and inward eye movements. This nerve is not involved in measuring visual acuity.

A) The partner places the client's arm above the level of the client's heart:
This action indicates that further instruction is needed. For an accurate blood pressure reading, the arm should be at heart level (approximately at the level of the fourth intercostal space) when taking the measurement. If the arm is placed above the heart, it can result in a falsely low reading. If the arm is positioned below the heart, it can lead to a falsely high reading. The position of the arm is crucial for obtaining an accurate blood pressure measurement.

B) The partner centres the cuff bladder over the client's brachial artery:
This is the correct technique. The cuff bladder should be centered over the brachial artery for accurate readings. Proper cuff placement ensures the best possible measurement and avoids errors in reading due to misplacement.

C) The partner wraps the blood pressure cuff around the client's arm using firm pressure:
This is also correct. The cuff should be wrapped snugly around the upper arm with firm pressure to ensure that it fits properly. If the cuff is too loose or too tight, it may give inaccurate readings. However, it should never be excessively tight.

D) The partner checks the instrument gauge to ensure the reading starts at zero:
This is a correct action. Before using a blood pressure cuff, it is important to check that the gauge starts at zero when the cuff is deflated. This ensures the manometer is calibrated properly and provides accurate readings. If the gauge does not start at zero, it should be recalibrated or replaced.