A nurse is collecting data about a client's cranial nerves. Which of the following methods should the nurse use to identify a problem with cranial nerve II?

Assess the 6 cardinal gazes

Ask the client to her clench teeth.

Anticipate the use of a tonometer

Use a Snellen chart.

Answer and Explanation

The Correct Answer is D

a) Assess the 6 cardinal gazes: This test assesses cranial nerve III, IV, and VI (oculomotor, trochlear, and abducens), which control eye movement, not the optic nerve.
b) Ask the client to clench teeth: This tests cranial nerve V (trigeminal nerve), which controls sensation in the face and motor functions like chewing.
c) Anticipate the use of a tonometer: A tonometer measures intraocular pressure (IOP), which is related to glaucoma, but it does not specifically assess cranial nerve II.
d) Use a Snellen chart: The Snellen chart is used to test visual acuity, which evaluates the function of cranial nerve II (optic nerve).

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Correct Answer is C

Explanation

a) Leaving the bed in the highest position: This could create a fall risk for the visually impaired person, so it is not an appropriate intervention.
b) Leaving the radio on all the time to help the patient know the time of day: While this may provide some information, it is not the most effective approach for supporting a visually impaired client.
c) Announcing your presence when you enter and leave the room: This is an essential intervention to orient a visually impaired person and help them understand the environment.
d) Keeping the door closed: This could pose a safety risk by limiting the client’s ability to orient to the surroundings. It is generally better to keep doors open for better access and awareness.

A. "I expect to have moderately severe pain for 1-2 days." B. "I will take a stool softener until my eye is healed." C. "I will refrain from cooking for 1 week." D. "I will bend at the waist to tie my shoes."

Correct Answer is B

Explanation

a) "I expect to have moderately severe pain for 1-2 days." Pain after cataract surgery is usually mild to moderate and typically improves significantly within a few hours to a day. Severe pain should be reported to the healthcare provider.
b) "I will take a stool softener until my eye is healed." This statement reflects appropriate teaching, as stool softeners are commonly used after eye surgery to avoid straining during bowel movements, which could increase intraocular pressure.
c) "I will refrain from cooking for 1 week." There is usually no need to refrain from activities like cooking unless the patient experiences significant discomfort or difficulty. Resting and avoiding strenuous activities are more common recommendations.
d) "I will bend at the waist to tie my shoes." Bending at the waist can increase intraocular pressure, which is contraindicated after cataract surgery. The client should be instructed to bend at the knees instead.

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A nurse is collecting data about a client's cranial nerves. Which of the following methods should the nurse use to identify a problem with cranial nerve II?

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