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 ["A","C","D"]

Explanation

A) Texture: Assessing the texture of the skin is an important part of a comprehensive skin assessment. It provides insights into the health and hydration status of the skin. Normal skin texture should feel smooth and even, while changes can indicate issues such as dryness or conditions like eczema or psoriasis.

B) Tachypnea: This term refers to an increased respiratory rate and is not a characteristic assessed in the skin. While it can indicate a physiological response to various conditions, it does not relate to skin health or characteristics and therefore is not relevant in this context.

C) Turgor: Skin turgor refers to the elasticity and hydration status of the skin, which can be assessed by pinching the skin. Proper turgor indicates adequate hydration, while decreased turgor can signal dehydration or other health issues. This is an essential component of skin assessment.
D) Temperature: Assessing the temperature of the skin can provide information about circulation and potential inflammation or infection. Normal skin temperature should feel warm and consistent, while variations can suggest underlying conditions such as fever or shock.

E) Tympany: Tympany is a term used in percussion assessments of the abdomen and is not applicable to skin assessment. It refers to a hollow sound produced by tapping on a body surface and does not pertain to skin characteristics.

A. "Please remove all jewellery so that I can conduct a full assessment." B. "I will be touching your skin as part of the process." C. "I will turn the temperature down in the exam room before we begin." "Use this blanket to cover up until we are ready to begin." D. "I will need you to take off your head dress for the entire examination."

Correct Answer is ["A","B","D"]

Explanation

For a thorough assessment of the integumentary system, the nurse should provide the following instructions:

A. "Please remove all jewellery so that I can conduct a full assessment."

This is correct. Jewelry can obstruct the assessment of skin, especially in areas like the neck, chest, and hands, where it may cover or hide skin abnormalities.

B. "I will be touching your skin as part of the process."

This is correct. A thorough integumentary assessment involves palpating the skin to check for texture, moisture, temperature, and other characteristics. It's important for the client to be informed that touch will be involved.

C. "I will turn the temperature down in the exam room before we begin." "Use this blanket to cover up until we are ready to begin."

This is partially correct. The temperature in the exam room should be comfortable, but turning it down may not be necessary. The instruction to cover with a blanket is appropriate to preserve the client's privacy and warmth until the assessment begins.

D. "I will need you to take off your head dress for the entire examination."

This is correct. If the head dress covers the scalp or areas that need to be examined (like the scalp, ears, or face), it should be removed to allow for a full assessment of the integumentary system.

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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?

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

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

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The nurse is preparing a client for a thorough assessment of the integumentary system. Which instructions should the nurse provide the client? Select all that apply.

Correct Answer is ["A","B","D"]

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