A nurse is performing a neurological assessment for a client who has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

Ask the client to shrug his shoulders against passive resistance

Instruct the client to look up and down without moving his head

Observe the client's ability to smile and frown

Have the client stand with his eyes closed and touch his nose

Answer and Explanation

The Correct Answer is B

Choice A: Ask the client to shrug his shoulders against passive resistance is not an assessment that will give the nurse information about the function of cranial nerve III. This assessment will test the function of cranial nerve XI, which is the accessory nerve. The accessory nerve innervates the trapezius and sternocleidomastoid muscles, which are involved in shoulder and neck movements.

Choice B: Instruct the client to look up and down without moving his head is an assessment that will give the nurse information about the function of cranial nerve III. Cranial nerve III is the oculomotor nerve, which innervates four of the six extraocular muscles that control eye movements. The oculomotor nerve also controls pupil size and lens shape. By instructing the client to look up and down without moving his head, the nurse can assess the ability of the oculomotor nerve to move the eyes vertically and adjust to diﬀerent distances.

Choice C: Observe the client's ability to smile and frown is not an assessment that will give the nurse information about the function of cranial nerve III. This assessment will test the function of cranial nerve VII, which is the facial nerve. The facial nerve innervates the muscles of facial expression, which are involved in smiling, frowning, blinking, and other facial movements.

Choice D: Have the client stand with his eyes closed and touch his nose is not an assessment that will give the nurse information about the function of cranial nerve III. This assessment will test the function of cranial nerve VIII, which is the vestibulocochlear nerve. The vestibulocochlear nerve innervates the inner ear and is responsible for hearing and balance. By having the client stand with his eyes closed and touch his nose, the nurse can assess the ability of the vestibulocochlear nerve to maintain equilibrium and coordination.

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Correct Answer is C

Explanation

Choice A Reason: This is incorrect. The balloons should not be deﬂated without a physician's order, as this can cause rebleeding or aspiration.

Choice B Reason: This is incorrect. The head of the bed should be elevated to 30 to 45 degrees to reduce pressure on the balloons and prevent gastric reﬂux.

Choice C Reason: This is correct. The nurse should monitor the client closely for signs of complications, such as airway obstruction, aspiration, or balloon rupture. The nurse should also keep scissors at the bedside to cut the tube and release the balloons in case of an emergency.

Choice D Reason: This is incorrect. The tube should not be suctioned, as this can damage the mucosa and cause bleeding. The nurse should only aspirate gastric contents through the gastric lumen to decompress the stomach.

A. Place ice to the bridge of the client’s nose. B. Tilt the client's head backward C. Move the client into high-Fowler’s position. D. Instruct the client to blow his nose. E. Apply pressure to the nares.

Correct Answer is ["A","C","E"]

Explanation

Choice A Reason: This is correct because placing ice to the bridge of the client’s nose can cause vasoconstriction and reduce blood ﬂow to the nasal mucosa.

Choice B Reason: This is incorrect because tilting the client's head backward can cause blood to drain into the throat and increase the risk of aspiration, nausea, and vomiting.

Choice C Reason: This is correct because moving the client into high-Fowler position can lower the blood pressure in the head and neck and decrease bleeding.

Choice D reason Reason This is incorrect because instructing the client to blow his nose can dislodge any clots that have formed and worsen bleeding.

Choice E Reason: This is correct because applying pressure to the nares can compress the bleeding site and promote clotting.

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