The advanced practice registered nurse (APRN) suspects a trigeminal nerve (cranial nerve V) injury in a patient presenting with difficulty chewing. What tool will the APRN choose to complete the assessment?
Flashlight
Cotton swab
Snellen chart
Tuning fork
The Correct Answer is B
A. Flashlight is incorrect because it is primarily used to assess pupillary reactions (cranial nerves II and III) or to inspect the oral cavity. While a flashlight helps with visual inspection and pupil response testing, it does not evaluate the sensory or motor functions of the trigeminal nerve, which are essential for diagnosing its injury.
B. Cotton swab is correct because the trigeminal nerve has both sensory and motor components. The sensory function is responsible for facial sensation across three divisions: ophthalmic, maxillary, and mandibular. The APRN uses a cotton swab to lightly touch different regions of the face, including the forehead, cheeks, and jawline, to assess the patient’s ability to feel light touch. The motor function controls the muscles of mastication, which are essential for chewing. The APRN can assess this by asking the patient to clench their teeth, move the jaw from side to side, or resist jaw opening. Using both observations helps identify trigeminal nerve injury, which may manifest as loss of facial sensation, weakness in jaw movement, or difficulty chewing.
C. Snellen chart is incorrect because it is used to assess visual acuity, which evaluates cranial nerve II (optic nerve). It provides no information about facial sensation or the ability to chew, so it is not appropriate for trigeminal nerve assessment.
D. Tuning fork is incorrect because it is used to assess hearing (cranial nerve VIII) or vibratory sensation in peripheral nerves. While useful in other neurological assessments, it does not provide data on trigeminal nerve function, either sensory or motor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Upper respiratory tract infection 5 days ago is correct because acute otitis media commonly develops as a complication of a recent upper respiratory tract infection (URTI). The infection causes eustachian tube dysfunction, leading to fluid accumulation in the middle ear, which becomes infected. This results in a bulging, erythematous (red), and distorted tympanic membrane, along with ear pain, especially in children.
B. Missed Measles, Mumps, Rubella (MMR) vaccine is incorrect because although vaccines prevent serious viral illnesses, missing the MMR vaccine is not a direct cause of acute otitis media. The child’s symptoms are consistent with a bacterial middle ear infection, not a vaccine-preventable viral illness.
C. Constant chewing of sugar free gum is incorrect because chewing gum may affect the temporomandibular joint (TMJ) or ear pressure slightly, but it does not cause a bulging tympanic membrane or infection.
D. Increased intake of sweets for the last 3 days is incorrect because diet, including sugar intake, does not directly cause middle ear infections. While excessive sugar may impact general health, it is not associated with acute otitis media.
Correct Answer is ["A","D"]
Explanation
A. Kernig sign is correct because it assesses meningeal irritation. The APRN flexes the patient’s hip and knee to 90° and then attempts to extend the knee. Pain or resistance in the hamstrings during this maneuver is a positive Kernig sign, suggestive of meningeal inflammation, commonly seen in meningitis.
B. Murphy’s sign is incorrect because it is used to assess cholecystitis. Pain and inspiratory arrest upon palpation of the right upper quadrant occurs during Murphy’s test, which is unrelated to meningeal inflammation.
C. Trendelenburg sign is incorrect because it assesses hip abductor muscle weakness, particularly in gluteus medius or minimus weakness, often associated with hip disorders. It does not assess meningeal irritation.
D. Brudzinski sign is correct because it also evaluates meningeal irritation. When the APRN flexes the patient’s neck forward, involuntary hip and knee flexion indicates a positive Brudzinski sign, which is highly suggestive of meningitis.
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