During an assessment of the cranial nerves, the nurse finds the following: Asymmetry when the client frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and an escape of air from the right side when the client puffs their cheeks. This would indicate the dysfunction of which of the cranial nerves?

Motor component of IV (Trochlear)

Motor and sensory components of XI (Accessory)

Motor component of VII (Facial)

Motor component of X (Vagus) and sensory component of XII (Hypoglossal)

Answer and Explanation

The Correct Answer is C

A) Motor component of IV (Trochlear): The trochlear nerve primarily controls the superior oblique muscle of the eye, which is responsible for downward and lateral eye movements. The findings described do not relate to eye movement and therefore do not indicate dysfunction of this nerve.

B) Motor and sensory components of XI (Accessory): The accessory nerve innervates the sternocleidomastoid and trapezius muscles, primarily affecting head rotation and shoulder elevation. The symptoms noted in the assessment do not pertain to these muscle functions, so this option is not correct.

C) Motor component of VII (Facial): The signs of asymmetry in frowning, uneven eyebrow lifting, sagging eyelids, and air escaping when puffing the cheeks are characteristic of dysfunction in the facial nerve (cranial nerve VII). This nerve controls the muscles of facial expression, and impairment would lead to the described asymmetrical movements.

D) Motor component of X (Vagus) and sensory component of XII (Hypoglossal): The vagus nerve affects autonomic functions and some swallowing muscles, while the hypoglossal nerve controls tongue movements. Neither nerve is primarily responsible for the facial expressions described in the assessment findings, making this option incorrect.

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Correct Answer is ["A","C","D","E"]

Explanation

A) Impact on ADLs: Understanding how pain affects a client's activities of daily living (ADLs) is crucial for assessing the overall impact of the pain on their life. It provides insight into the functional limitations caused by the pain and helps guide treatment planning.

B) Family medical history: While family medical history can provide context for certain conditions, it is not an essential component of a focused pain assessment. The immediate concerns are more directly related to the client's current pain experience rather than their family's medical background.

C) Pain intensity rating: Assessing the intensity of pain is a fundamental aspect of pain assessment. Using scales (e.g., 0-10) allows the nurse to quantify the pain, monitor changes over time, and evaluate the effectiveness of interventions.

D) Characteristics of the pain: Understanding the characteristics of the pain—such as its quality (sharp, dull, throbbing) and location—is essential for determining its cause and guiding appropriate treatment strategies.

E) Aggravating factors: Identifying what exacerbates the pain is critical for understanding its nature and developing effective management strategies. Knowing which activities or positions worsen the pain can help in creating a comprehensive care plan tailored to the client's needs.

A. The patient has asthma. B. The patient has cardiovascular disease. C. The patient has emphysema. D. The patient has chronic hypoxemia.

Correct Answer is D

Explanation

A) The patient has asthma: While asthma can lead to respiratory symptoms and issues, it is not typically associated with clubbing of the fingernails. Asthma primarily affects airway constriction and inflammation, rather than causing the long-term changes in nail morphology seen with clubbing.

B) The patient has cardiovascular disease: Although some cardiovascular conditions can lead to clubbing, it is more commonly associated with chronic lung diseases. Cardiovascular disease might cause other signs or symptoms, but clubbing alone is not a definitive indicator of this condition.

C) The patient has emphysema: Emphysema, a type of chronic obstructive pulmonary disease (COPD), is characterized by the destruction of lung tissue and impaired airflow. While it can contribute to hypoxemia, clubbing is not a common finding specifically associated with emphysema.
D) The patient has chronic hypoxemia: Clubbing of the fingernails is a classic sign of chronic hypoxemia, often resulting from long-term respiratory conditions like COPD, interstitial lung disease, or lung cancer. It indicates a prolonged lack of oxygen in the blood, leading to changes in the nail bed and digit shape. Given the patient's long smoking history, chronic hypoxemia is the most likely explanation for this finding.

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client admitted with severe back pain. Which are essential components of the pain assessment? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

The nurse is performing an integumentary system assessment of a patient who has smoked for the last 40 years. The patient has clubbing of the fingernails. What does this finding indicate to the nurse?

Correct Answer is D

Explanation

When assessing the abdomen, the nurse would expect to auscultate which sounds?

When conducting a peripheral vascular assessment on the upper extremities of a client, the nurse should include which assessments? Select all that apply

When child, elder, or vulnerable adult abuse or neglect is disclosed, what is the nurse's responsibility?

How can a nurse best assess a patient's dietary habits effect on their overall health?

Which of the following is the rationale for the nurse to reassess the patient's pain after treatment?

A patient, employed as a carpenter, has difficulty holding tools because of peripheral neuropathy from carpal tunnel syndrome. What is the nurse's priority concern for this patient?

The nurse is completing their documentation for the shift. Which of the data is objective? Select all that apply.