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 C

Explanation

A) Tricuspid and mitral: The tricuspid and mitral valves are best auscultated over the areas where the heart's valves are closest to the chest wall, specifically at the lower left sternal border and the apex, respectively. A louder S2 in the 2nd intercostal space right sternal border does not indicate the closure of these valves.
B) Mitral and aortic: The mitral valve is auscultated at the apex, and the aortic valve is best heard at the 2nd intercostal space right sternal border. While a louder S2 may be associated with the aortic valve, it is not consistent with the mitral valve.
C) Aortic and pulmonic: The aortic valve and pulmonic valve are located in the areas where S2 (second heart sound) is predominantly heard. The aortic valve is located at the 2nd intercostal space right sternal border, and the pulmonic valve is heard at the 2nd intercostal space left sternal border. A louder S2 in the 2nd intercostal space right sternal border indicates a louder closure of the aortic valve and potentially the pulmonic valve as well.
D) Pulmonic and tricuspid: The pulmonic valve is auscultated at the 2nd intercostal space left sternal border, while the tricuspid valve is heard best at the lower left sternal border. A louder S2 in the 2nd intercostal space right sternal border does not indicate the closure of the tricuspid valve.

A. Tension headache B. Migraine headache C. Cluster headache D. Sinus headache

Correct Answer is B

Explanation

A) Tension headache: Tension headaches are typically characterized by a dull, aching pain that feels like a tight band around the head. They are often associated with muscle tension and stress, and they generally do not involve nausea, vomiting, or sensitivity to light and sound, which are more indicative of migraines.
B) Migraine headache: The symptoms described—severe pain rated 10 out of 10, nausea, vomiting, and sensitivity to light (photophobia) and sound (phonophobia)—are classic signs of a migraine headache. Migraines are often intense and can be accompanied by these additional symptoms, making this the most likely diagnosis.
C) Cluster headache: Cluster headaches are extremely painful and typically occur in cyclical patterns or clusters. They are often unilateral (one-sided) and can cause severe pain, redness of the eye, and nasal congestion. While they can be very painful, they are less commonly associated with nausea, vomiting, and sensitivity to light and sound as described in the scenario.
D) Sinus headache: Sinus headaches are associated with sinusitis and typically involve pain and pressure in the forehead, cheeks, or nose area, often accompanied by nasal congestion. They usually do not present with the intensity of pain, nausea, vomiting, and sensitivity to light and sound seen in migraines.

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

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Naxlex Comprehensive Predictor Exams

When auscultating a client's heart sounds, the nurse hears a louder S2 when listening at the 2nd intercostal space right sternal border. The nurse determines that this finding is consistent with the closure of which heart valves?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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