During the assessment of a client's head and neck, the nurse observes the client's facial expressions and the face for symmetry and movement. Which cranial nerve is the nurse assessing?

VII

III

Answer and Explanation

The Correct Answer is A

A) VII: The facial nerve (cranial nerve VII) is responsible for controlling the muscles of facial expression. By assessing facial symmetry and movement, the nurse evaluates the integrity and function of this nerve, which is crucial for activities such as smiling, frowning, and raising eyebrows.

B) V: The trigeminal nerve (cranial nerve V) is primarily responsible for sensation in the face and motor functions such as chewing. While it plays a role in facial movement, it does not specifically assess facial expressions.

C) III: The oculomotor nerve (cranial nerve III) controls eye movement and pupil constriction. It does not directly influence facial expressions, so it is not the nerve being assessed in this context.

D) VI: The abducens nerve (cranial nerve VI) is responsible for lateral eye movement. It is unrelated to facial expression or symmetry and is not the focus of this assessment.

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Correct Answer is B

Explanation

A) The patient's integumentary system is within normal limits for his age: While thinning skin and decreased turgor can be common in older adults, the specific combination of findings, including the patient feeling cold, suggests that further investigation is warranted rather than assuming they are normal.
B) The patient may have a metabolic condition causing him to feel cold: Thin skin and non-elastic turgor can be indicative of aging, but the sensation of always feeling cold may point to an underlying metabolic condition, such as hypothyroidism or poor circulation, which can affect thermoregulation.

C) The patient has abnormal thinning of skin: While skin thinning is common in older adults, it is not necessarily "abnormal" in the context of aging. However, in conjunction with other symptoms like non-elastic turgor and cold sensitivity, it may warrant further evaluation.

D) The patient should have elastic turgor: In older adults, it is common to see decreased elasticity and turgor of the skin. Therefore, expecting the patient to have elastic turgor may not be appropriate, as it reflects the natural aging process rather than a healthy standard.

A. +10 B. +4 C. +5 D. +1

Correct Answer is C

Explanation

A) +10: This score does not exist on the muscle function grading scale, which typically ranges from 0 to 5. Using +10 could confuse the assessment and misrepresent the client's strength.
B) +4: This score indicates good strength against some resistance but not full strength. It suggests that the client has nearly complete function but may still have some limitations in range or strength.
C) +5: This score signifies full muscle strength and complete range of motion in a joint without any limitations. A score of +5 is what you would expect for a client demonstrating full strength, indicating optimal muscle function.
D) +1: This score indicates trace muscle contraction with minimal movement, which is far from the full strength described in the question. It suggests severe weakness and would not apply in this case.

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During the assessment of a client's head and neck, the nurse observes the client's facial expressions and the face for symmetry and movement. Which cranial nerve is the nurse assessing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assessing a 90-year-old patient notes that his skin is thin and turgor is non-elastic. The patient states that he always seems to be cold. What does the nurse know about these assessment findings?

Correct Answer is B

Explanation

Which score would a nurse select from the muscle function grading scale if the client has full strength and range of motion in a given joint?

Correct Answer is C

Explanation

The nurse notes which of the following about the patient's skin during her morning assessment? Select all that apply.

A patient states, "I feel like the whole room is spinning around me, and it makes me feel nauseous sometimes." That term will the nurse use to document the patient's symptom?

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The nurse is using inspection to assess the breasts of a female client. Which finding should the nurse anticipate documenting?

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