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.
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).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a) "I will bend at my knees if I need to pick something up off of the floor." This statement shows an understanding of the importance of avoiding bending over at the waist post-surgery, which can increase intraocular pressure and disrupt the healing process.
b) "I can begin lying on my operative side 24 hours after my surgical procedure." Lying on the operative side should be avoided to prevent pressure on the healing eye.
c) "I will take a dose of aspirin if I have pain in the area of my eyebrow." Aspirin should generally be avoided after cataract surgery due to its anticoagulant effects, which may increase the risk of bleeding.
d) "I can pick up a sack of groceries that weighs 15 pounds." Lifting heavy objects is discouraged after cataract surgery to avoid putting pressure on the eye and affecting healing.
Correct Answer is C
Explanation
a) Normal hearing: In normal hearing, air conduction (AC) should be greater than bone conduction (BC), meaning BC > AC is not a normal finding.
b) Cochlear defect: A cochlear defect would result in sensorineural hearing loss, which would show a normal Rinne test (AC > BC).
c) Conductive hearing loss: BC > AC indicates conductive hearing loss, where sound transmission through the external or middle ear is impaired, allowing bone conduction to be heard more clearly than air conduction.
d) Sensorineural hearing loss: Sensorineural hearing loss typically shows a normal or positive Rinne test (AC > BC), as the issue lies with the inner ear or auditory nerve, not the conduction of sound.
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