A nurse is preparing to assess a client. Which action should the nurse take to check cranial nerve VI?
Open the client’s visual acuity using a Snellen chart.
Whisper none of the client’s ears while blocking the other.
Ask the client to inspect up.
Ask the client to smile.
The Correct Answer is C
Choice A Reason:
Open the client’s visual acuity using a Snellen chart is incorrect. This action assesses cranial nerve II (optic nerve), which is responsible for vision. The Snellen chart is used to measure visual acuity, not the function of cranial nerve VI
Choice B Reason:
Whisper none of the client’s ears while blocking the other is incorrect. This action assesses cranial nerve VIII (vestibulocochlear nerve), which is responsible for hearing and balance. Whispering tests the auditory function of this nerve.
Choice C Reason:
Ask the client to inspect up is correct. Cranial nerve VI (abducens nerve) controls the lateral rectus muscle, which is responsible for moving the eye outward. Asking the client to look up and outward helps assess the function of this nerve.
Choice D Reason:
Ask the client to smile is incorrect. This action assesses cranial nerve VII (facial nerve), which controls the muscles of facial expression. Smiling tests the motor function of this nerve.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Reminding the client that a signed informed consent form is a legally binding document is incorrect. Informed consent is based on the principle of patient autonomy, meaning the patient has the right to withdraw consent at any time. The nurse should respect the client’s decision and not pressure them into proceeding with the procedure.
Choice B reason: Notifying the surgeon that the client wishes to withdraw informed consent for the procedure is the appropriate action. The surgeon needs to be informed immediately so that they can discuss the client’s concerns, provide additional information if needed, and respect the client’s decision. This ensures that the client’s autonomy and rights are upheld.
Choice C reason: Proceeding with preparation of the patient for the surgical procedure is not appropriate once the client has withdrawn consent. Continuing with the preparation would violate the client’s rights and could lead to legal and ethical issues. The nurse must halt any further preparation and inform the relevant medical staff of the client’s decision.
Choice D reason: Informing the surgical team to cancel the client’s surgery is a step that may be taken after discussing the withdrawal of consent with the surgeon. The nurse should first notify the surgeon, who will then make the decision to cancel the surgery based on the client’s wishes. Directly informing the surgical team without consulting the surgeon first is not the correct protocol.
Correct Answer is ["1"]
Explanation
We know:
- The prescribed dose is 25 mg.
- The available concentration is 125 mg per 5 mL.
Step 2 is to set up the calculation.
We will use the formula: (Desired Dose in mL) = (Prescribed Dose in mg × Volume Available in mL) ÷ Concentration Available in mg
Step 3 is to plug in the values into the formula.
(Desired Dose in mL) = (25 mg × 5 mL) ÷ 125 mg
Step 4 is to perform the multiplication first.
25 mg × 5 mL = 125
Step 5 is to perform the division.
125 ÷ 125 mg = 1 mL
Step 6 is the result.
The nurse should administer 1 mL per dose.
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