A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve VII?

Check the client's visual acuity using a Snellen chart.

Observe for facial symmetry while the client smiles.

Have the client identify specific smells.

Whisper in one of the client's ears while occluding the other.

Answer and Explanation

The Correct Answer is B

A.   Check the client's visual acuity using a Snellen chart: This assesses cranial nerve II (optic), not cranial nerve VII.
B.   Observe for facial symmetry while the client smiles: This is the correct method to assess cranial nerve VII (facial nerve), which controls facial muscles, including those responsible for smiling.
C.   Have the client identify specific smells: This tests cranial nerve I (olfactory), not cranial nerve VII.

D.   Whisper in one of the client's ears while occluding the other: This assesses cranial nerve VIII (vestibulocochlear), not cranial nerve VII.

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Correct Answer is A

Explanation

A. Pinnae of the ears are one of the most reliable sites for detecting cyanosis in individuals with dark skin, as the color changes are more apparent in the mucous membranes and earlobes.
B. Dorsal surface of the hand may not reliably show cyanosis in darker skin tones, and it’s often less
visible.
C. Dorsal surface of the foot is not typically where cyanosis would be identified.
D. Conjunctivae can be used for detection in individuals with darker skin, but it is typically harder to visualize than the pinna.

A. Check the function of cranial nerve V. B. Observe for the presence of Kernig's sign. C. Inspect for the presence of clubbing. D. Perform a Romberg's test.

Correct Answer is D

Explanation

A. Cranial nerve V (trigeminal) is not directly related to ataxia or balance. It is more involved in sensory perception of the face and motor function for chewing.
B. Kernig's sign is a test for meningitis, not ataxia or balance issues. It involves flexing the hips and knees to check for resistance or pain that may suggest meningeal irritation.
C. Clubbing is related to chronic oxygenation issues or respiratory/cardiovascular conditions, but it is not a direct assessment of ataxia or balance.
D. A Romberg's test is used to assess balance and proprioception. By having the client stand with feet together and eyes closed, the nurse can assess the client's ability to maintain balance and identify any unsteadiness or ataxia that may impair safe ambulation.

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A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve VII?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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