During an assessment of the cranial nerves, the nurse asks the client to smile, frown, wrinkle the forehead, and puff out the cheeks. Which nerve is affected? being tested?

Cranial nerve I

Cranial nerves II and III

Cranial nerve VII

Cranial nerve VIII

Answer and Explanation

The Correct Answer is C

Choice A reason: Cranial nerve I (olfactory) assesses smell, not facial movements. Smiling or frowning involves facial muscles, unrelated to olfactory function. Testing nerve I involves odor identification, not motor actions, making it irrelevant to this assessment, per cranial nerve examination protocols.

Choice B reason: Cranial nerves II (optic) and III (oculomotor) control vision and eye movement, not facial expressions. Actions like smiling or puffing cheeks involve facial muscles, not pupil response or gaze, which are tested for II and III, per neurological assessment standards.

Choice C reason: Cranial nerve VII (facial) controls facial expressions, including smiling, frowning, wrinkling the forehead, and puffing cheeks. Testing these actions assesses motor function, confirming nerve integrity. This is a key part of neurological exams, detecting deficits like Bell’s palsy, per cranial nerve assessment guidelines.

Choice D reason: Cranial nerve VII (vestibulocochlear VIII (auditory) assesses hearing and balance, not facial movements. Actions like smiling or puffing cheeks are unrelated to auditory or vestibular function, making this nerve irrelevant to the described assessment, per neurological examination protocols.

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Correct Answer is C

Explanation

Choice A reason: Labeling the action as libel, a felony, is incorrect, as libel involves defamatory statements, not clinical errors. Negligence relates to failing to meet care standards, not legal defamation. This mischaracterizes the issue, focusing on legal terms irrelevant to the failure to report critical hypertension, per nursing liability.

Choice B reason: While poor interprofessional communication may have contributed, it does not fully capture the negligence. The primary issue is not reporting a critical blood pressure (202/122), which a prudent nurse would address. Communication is secondary to the nurse’s failure to act on a life-threatening finding, per professional standards.

Choice C reason: Failing to act as a prudent nurse under similar circumstances defines negligence, as not reporting 202/122 mmHg endangered the patient, leading to ICU transfer. A reasonable nurse would have notified the provider, preventing harm, aligning with legal and ethical standards of care and accountability.

Choice D reason: Not reassessing blood pressure is relevant but not the core negligence. The primary issue is failing to report the critical reading, which required immediate action. Reassessment alone would not address the urgency of notifying the provider, making this less comprehensive than negligence, per standards.

A. Having chest pain B. Pulse rate of 108 C. History of angina D. Oxygen is needed.

Correct Answer is C

Explanation

Choice A reason: In SBAR (Situation, Background, Assessment, Recommendation), chest pain is part of the Situation (S), describing the current issue. Background (B) includes relevant medical history, like angina, which causes chest pain due to myocardial ischemia from reduced coronary blood flow. Chest pain is the presenting symptom, not historical context, making it incorrect for B.

Choice B reason: Pulse rate of 108 is part of the Assessment (A) in SBAR, reflecting current vital signs. Background (B) provides historical context, such as the patient’s angina diagnosis, which predisposes to myocardial ischemia. Tachycardia may result from pain or hypoxia but is a current finding, not historical data, making it incorrect for B.

Choice C reason: History of angina is the Background (B) in SBAR, providing relevant medical history. Angina, caused by coronary artery narrowing, reduces myocardial oxygen supply, leading to chest pain. This context informs the current episode of pain and tachycardia, guiding assessment and treatment, making it the correct data for the Background component.

Choice D reason: Oxygen is needed is part of the Recommendation (R) in SBAR, suggesting an intervention. Background (B) includes past medical history, like angina, which explains the patient’s predisposition to chest pain. Recommending oxygen addresses current hypoxia but is not historical data, making it inappropriate for the Background section of SBAR.

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During an assessment of the cranial nerves, the nurse asks the client to smile, frown, wrinkle the forehead, and puff out the cheeks. Which nerve is affected? being tested?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse pulls a new nurse to the side to discuss documenting a patient’s blood pressure of 202/122 mmHg without reporting it. The patient is now in the ICU. How does the charge nurse best explain how this reflects negligence?

Correct Answer is C

Explanation

A patient was admitted 2 days ago with pneumonia and a history of angina. The patient is now having chest pain with a pulse rate of 108. Using the SBAR, which piece of data will the nurse use for B?

Correct Answer is C

Explanation

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