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","D"]
Explanation
Choice A Reason:
Date of birth is an acceptable client identifier. The Joint Commission specifies that using the date of birth helps ensure accurate identification of the client. This identifier is unique to each individual and is less likely to be duplicated.
Choice B Reason:
Photograph identification is not typically listed as an acceptable identifier by the Joint Commission. While it can be useful in some settings, it is not one of the primary identifiers recommended for ensuring patient safety.
Choice C Reason:
Facility room number is not an acceptable client identifier. The Joint Commission explicitly states that room numbers should not be used as identifiers because they can change and are not unique to the individual.
Choice D Reason:
Client’s full name is an acceptable client identifier. Using the full name helps to accurately identify the client and match them with their medical records and treatment plans.
Correct Answer is D
Explanation
Choice A reason: To provide a means for medication administration
A Jackson-Pratt (JP) drain is not used for medication administration. Its primary function is to remove fluids that accumulate in a surgical site, which helps to prevent infection and promote healing. Medication administration is typically done through other means such as intravenous (IV) lines or oral medications.
Choice B reason: To eliminate the need for wound dressings
The JP drain does not eliminate the need for wound dressings. Dressings are still required to protect the wound site, absorb any additional drainage, and prevent infection. The JP drain works in conjunction with dressings to manage wound care effectively.
Choice C reason: To limit the amount of bleeding from the surgical site
While the JP drain can help manage bleeding by removing accumulated blood, its primary purpose is not to limit bleeding. Instead, it is designed to prevent the buildup of fluids, including blood, which can lead to complications such as hematomas or infections.
Choice D reason: To prevent fluid from accumulating in the wound
The primary purpose of a Jackson-Pratt (JP) drain is to prevent fluid from accumulating in the wound. This includes blood, lymphatic fluid, and other bodily fluids that can collect at the surgical site. By removing these fluids, the JP drain helps to reduce the risk of infection, promote healing, and decrease the likelihood of complications.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today