A nurse is assessing a client’s cranial nerves. Which methods should the nurse use to assess cranial nerve V?
Ask the client to clench their teeth and assess facial sensation.
Ask the client to identify scented aromas.
Ask the client to read a Snellen chart.
Ask the client to raise his eyebrows.
The Correct Answer is A
Choice A Reason:
Cranial nerve V is the trigeminal nerve, which has both motor and sensory functions: Motor function: The nurse can assess this by asking the client to clench their teeth while palpating the masseter and temporalis muscles for strength. Sensory function: The nurse can assess this by lightly touching the client's face in different areas (forehead, cheeks, and jaw) with a cotton ball or sharp/dull object to check for sensation.
Choice B Reason:
Asking the client to identify scented aromas is a method used to assess cranial nerve I (Olfactory), not cranial nerve V. Cranial nerve V (Trigeminal) is assessed by testing facial sensation and motor functions such as chewing.
Choice C Reason:
Asking the client to read a Snellen chart is a method used to assess cranial nerve II (Optic), which is responsible for vision. This method does not assess cranial nerve V
Choice D Reason:
Asking the client to raise his eyebrows is a method used to assess cranial nerve VII (Facial), which controls facial expressions. This method is not used to assess cranial nerve V.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Age dose of pain medication refers to adjusting the dosage of pain medication based on the client’s age. Elderly clients often have different pharmacokinetics and pharmacodynamics compared to younger individuals, which means they may require lower doses of medication to achieve the same effect. This adjustment helps to prevent overmedication and potential side effects, ensuring safe and effective pain management for elderly clients.
Choice B Reason:
Correct method of administering your own pain medication is important for clients who are capable of self-administering their medication. However, this choice does not directly address the issue of balance deficit and the need for an assistive device. While proper medication administration is crucial, it is not the primary concern in this scenario.
Choice C Reason:
Operator can push the PCA button for you if you are asleep is not an appropriate practice. Patient-controlled analgesia (PCA) is designed to allow clients to self-administer pain medication as needed. Allowing someone else to push the button can lead to overmedication and potential complications. This choice does not address the need for an assistive device for balance deficit.
Choice D Reason:
The pain medication is delivered at your nose is not a standard method of pain medication administration. This choice is incorrect and does not relate to the client’s need for an assistive device for balance deficit. Pain medication is typically administered orally, intravenously, or through other appropriate routes, but not through the nose.
Correct Answer is A
Explanation
Choice A reason: This statement reflects denial, which is a common initial reaction in the grief process. The client is not accepting the reality of their prognosis and believes the doctor is exaggerating. Denial serves as a defense mechanism to protect the individual from the emotional impact of the diagnosis. It is a way for the client to cope with the overwhelming news by rejecting its truth.
Choice B reason: This statement reflects anger, another stage in the grief process. The client is expressing disbelief and frustration towards the doctor’s competence. Anger often follows denial and is directed towards others as a way to cope with the emotional pain. It is not indicative of denial but rather a progression in the grieving process.
Choice C reason: This statement reflects acceptance of the physical symptoms and the reality of the client’s condition. The client acknowledges their lack of energy and the impact of the illness on their daily life. This is not a sign of denial but rather an acceptance of their current state.
Choice D reason: This statement reflects acceptance and gratitude towards the doctor. The client recognizes the efforts made by the healthcare team and accepts that their time is limited. This is a sign of acceptance, the final stage in the grief process, where the individual comes to terms with their situation.
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