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

The Glasgow Coma Scale (GCS) measures three aspects: Eye response, verbal response, and motor response.

Eye response: Opens eyes to pain (score 2).

Verbal response: Uses inappropriate words (score 3). Motor response: Flexion withdrawal from pain (score 4). Total GCS = 2 (eyes) + 3 (verbal) + 4 (motor) = 9.

A. Pinpoint pupils B. Dorsiflexion of the great toe C. Jerking contractions of the head and neck D. Pronation of the arms

Correct Answer is B

Explanation

A. Pinpoint pupils: Pinpoint pupils may indicate opioid use or a brainstem injury but are not related to Babinski's sign.
B. Dorsiflexion of the great toe: This is the characteristic response for a positive Babinski sign, which occurs when the toes fan out and the big toe dorsiflexes (moves upward) when the sole of the foot is stroked. It indicates an abnormal response and potential upper motor neuron damage.
C. Jerking contractions of the head and neck: This is indicative of a seizure activity, not Babinski's sign.
D. Pronation of the arms: This could be indicative of decerebrate posturing, not Babinski's sign.

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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?

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