A nurse is preparing to measure the visual acuity of a client. The nurse should recognize that which nerve should be assessed?

Answer and Explanation

The Correct Answer is A

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A) Obtain a throat culture for possible streptococcal (strep) infection:
A throat culture for streptococcal infection is generally warranted when there are signs and symptoms of a bacterial infection, such as a sore throat, fever, exudate on the tonsils, or swollen lymph nodes. The description provided—involuted, granular tonsils with deep crypts—is a normal, age-related finding and not indicative of an infection. Therefore, obtaining a throat culture is unnecessary unless additional clinical signs of infection are present.

B) Continue with the assessment, looking for any other abnormal findings:
While it is always important to complete a thorough assessment and look for other abnormal findings, the specific characteristics described (involuted, granular tonsils with deep crypts) are normal, particularly in adults. This is a common finding and does not require further investigation unless accompanied by other symptoms such as pain, swelling, or visible pus, which would warrant a closer look.

C) Refer the client to their primary provider:
Referral to a primary provider is generally recommended if there are significant concerns about the tonsils, such as persistent swelling, pain, or signs of infection. However, the description provided does not suggest a pathological issue; these characteristics are typically considered normal in adults. Referral would only be necessary if additional concerning symptoms were present, such as fever, difficulty swallowing, or changes in voice.

D) No response is needed; this appearance is normal for the tonsils:
This is the correct response. Involuted (shrunken), granular tonsils with deep crypts are a normal, age-related finding, especially in adults. Over time, the tonsils tend to shrink and develop more pronounced crypts (pockets). This is part of the natural aging process and is not usually a sign of pathology. These tonsil changes are often seen in individuals who have had repeated infections or as part of the natural aging process.

A. When the client is obese B. When part of the lung is obstructed or collapsed C. When accessory muscles are used to facilitate respiratory effort D. When bulging of the intercostal spaces is present

Correct Answer is B

Explanation

A) When the client is obese:
While obesity can affect the overall ease of breathing due to increased fat tissue around the chest and abdomen, it is not a direct cause of unequal chest expansion. Obesity can limit the depth of breath and potentially make it harder for the chest to expand fully, but it would not typically cause asymmetry in the movement of the chest on one side. Unequal chest expansion is more likely to occur due to underlying respiratory or structural issues.

B) When part of the lung is obstructed or collapsed:
This is the most accurate reason for unequal chest expansion. If part of the lung is obstructed (such as with a mucous plug or foreign body) or collapsed (as in the case of pneumothorax or atelectasis), it prevents that area of the lung from fully expanding during inspiration. As a result, the affected side of the chest will expand less than the opposite side. This can be a critical finding and warrants immediate further investigation to determine the cause and ensure appropriate treatment.

C) When accessory muscles are used to facilitate respiratory effort:
While the use of accessory muscles (e.g., the sternocleidomastoid, scalene, and intercostal muscles) often occurs during labored breathing, it does not specifically result in unequal chest expansion. Accessory muscle use typically occurs in conditions like severe asthma, chronic obstructive pulmonary disease (COPD), or respiratory distress, where there is an increased effort to breathe, but it doesn't cause asymmetry in the chest's movement. Unequal chest expansion is usually related to a localized problem in the lung or pleura, not the general use of muscles.

D) When bulging of the intercostal spaces is present:
Bulging of the intercostal spaces may suggest increased pressure in the pleural space, such as in the case of a pleural effusion or severe respiratory distress. However, while bulging intercostal spaces can be a sign of a respiratory condition, it is not typically associated with unequal chest expansion. Instead, bulging could indicate that the lung or chest wall is under stress or that there is fluid accumulation, which would lead to other physical findings like decreased breath sounds or dullness to percussion, but it does not directly cause unequal expansion. Unequal expansion is more likely to occur when part of the lung is obstructed or collapsed

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is preparing to measure the visual acuity of a client. The nurse should recognize that which nerve should be assessed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the tonsils of a client and notes that the tonsils are involuted, granular in appearance, and have deep crypts. The nurse should recognize that which of the following is the correct response to these findings?

Correct Answer is D

Explanation

A nurse is performing an assessment of an adult client and observes unequal chest expansion. The nurse should recognize that unequal chest expansion I occur for which reason?

Correct Answer is B

Explanation

A nurse is conducting a class on Breast Self-Examination (BSE) for women of childbearing age. The nurse should include which of these statements that indicates the proper BSE technique?

A nurse is testing a client's visual accommodation. Which of the following should the nurse recognize as an assessment finding from visual accommodation?

A nurse is assessing the symmetry of a client's chest. The nurse should understand that which technique best confirms symmetric expansion of the chest?

A nurse is assessing a client for tactile fremitus. The nurse should recognize that it is normal to feel tactile fremitus most intensely over which location?

A nurse is documenting assessment findings on a client. Which of the following entries should the nurse identify as subjective data? (Select All that Apply.)

A nurse is assessing the anterior chest of a client. The nurse recognizes that which of the following should be included in the assessment? (Select all that apply.)

A nurse is auscultating the lungs of a sleeping client and hears short, popping, crackling breath sounds that stop after a few breaths. How should the nurse document these breath sounds in the client's medical record?

The nurse is discussing Breast Self Examination (BSE) with a postmenopausal client. What instructions should the nurse give to the client about the correct time to perform BSE?