How would the nurse assess CN VIII Acoustic, vestibulocochlear: Select all that Apply

Weber test

Magazine

Rhine test

Whispered voice test

Answer and Explanation

Correct Answer : A,C,D

A. Weber test: The Weber test is used to assess hearing by placing a vibrating tuning fork on the center of the forehead. It helps evaluate lateralization of sound and can indicate whether hearing loss is conductive or sensorineural. This test is pertinent for assessing CN VIII, which is responsible for hearing.
B. Magazine: This option is not relevant to the assessment of CN VIII. A magazine is not used in evaluating hearing or vestibular function. The appropriate assessments for CN VIII focus on hearing and balance.
C. Rinne test: The Rinne test involves placing a vibrating tuning fork on the mastoid bone and then near the ear canal to compare air conduction (AC) and bone conduction (BC) of sound. This test helps differentiate between conductive and sensorineural hearing loss and is directly related to assessing CN VIII.
D. Whispered voice test: This test involves the nurse whispering numbers or words while occluding one ear and assessing the client's ability to hear and repeat them. It is a simple way to assess hearing ability and thus evaluates the function of CN VIII.

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

Explanation

A) Trochlear: The trochlear nerve (CN IV) is responsible for innervating the superior oblique muscle, which helps control the downward and inward movement of the eye.
B) Optic: The optic nerve (CN II) is primarily involved in vision and visual acuity, not in the movement of the eye. It transmits visual information from the retina to the brain.
C) Oculomotor: The oculomotor nerve (CN III) controls most of the extraocular muscles, including those responsible for eye movement (superior rectus, inferior rectus, medial rectus, and inferior oblique) and also controls pupil constriction.
D) Abducens: The abducens nerve (CN VI) controls the lateral rectus muscle, which is responsible for the outward movement of the eye.
E) Facial: The facial nerve (CN VII) controls the muscles of facial expression and is not involved in eye movements.

A. Background B. Person C. Situation D. Place E. Time

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

Explanation

A) Background: Orientation to "background" is not a standard component of the "AOX3" (alert and oriented times three) assessment. Typically, orientation assessments focus on more specific elements such as person, place, and time, rather than background information.
B) Person: Orientation to "person" means that the patient is aware of who they are. This is a key aspect of the AOX3 assessment, which checks whether the patient can identify themselves correctly.
C) Situation: While awareness of the situation or current circumstances is important, "situation" is not included in the standard AOX3 assessment. The usual components are person, place, and time.
D) Place: Orientation to "place" means the patient knows where they are. This is a critical component of the AOX3 assessment, indicating that the patient can identify their current location.
E) Time: Orientation to "time" means that the patient is aware of the current date, day of the week, and time of day. This is another essential part of the AOX3 assessment, reflecting the patient's awareness of the temporal context.

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How would the nurse assess CN VIII Acoustic, vestibulocochlear: Select all that Apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which cranial nerves are involved in eye movements? Select all that apply.

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

Explanation

The nurse reads in the patient chart the doctor's day round note. The doctor writes AOX3, the nurse knows this means the patient is oriented to: Select all that apply.

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

Explanation

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