During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs?
Motor component of CN IV
Motor component of CN VI
Motor and sensory components of CNX
Motor component of CN VII
The Correct Answer is D
A. The trochlear nerve controls the superior oblique muscle of the eye and is not related to facial movements.
B. The abducens nerve controls the lateral rectus muscle of the eye, responsible for eye movement, not facial muscles.
C. The vagus nerve affects the soft palate, pharynx, and larynx, but does not contribute to facial expression.
D. Asymmetry in facial movements, like smiling, frowning, and puffing the cheeks, suggests dysfunction of the facial nerve (CN VII).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","F"]
Explanation
A. Skin turgor refers to the elasticity of the skin, which can be affected by various conditions, including malignancy. The nurse should assess for any skin changes near the lump to identify any unusual signs.
B. The nurse should document the precise location of the mass, noting whether it is near the nipple or in another quadrant of the breast. This will help with future imaging and assessment.
C. While the history is important, it does not fall under objective findings that the nurse would document during the physical exam.
D. This is part of the patient’s history, not a direct observation during the physical exam, so it is not included in the documentation of objective findings of the breast mass.
E. Orientation refers to the patient’s mental status and does not relate to the characteristics of the breast mass.
F. The nurse should note the consistency of the mass (e.g., hard, firm, or soft). A firm, non-tender mass is often concerning for malignancy and should be documented.
Correct Answer is D
Explanation
A. This grade indicates trace contraction but no movement. It is not appropriate in this case, as the patient has full range of motion.
B. Grade 2. This grade reflects full range of motion with gravity eliminated. The patient’s range of motion is against gravity, so this is not the correct grade.
C. Grade 3. This grade indicates full range of motion against gravity but without resistance. The patient is able to resist full force, so this is not the correct grade either.
D. Grade 5. This grade indicates normal strength with full range of motion against gravity and full resistance. This best describes the patient's strength, which is normal.
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