The neurologic assessment of a patient indicates impaired function of the glossopharyngeal (CN IX) and the vagus nerve (CN X). Based on these findings the nurse plans to:

Insert an oral airway and suction as necessary.

Withhold oral fluids or foods.

Speak clearly while facing the client.

Apply artificial tears to protect the cornea.

Answer and Explanation

The Correct Answer is B

A. Inserting an oral airway and suctioning may be indicated for airway management, but the primary concern is the impaired function of the glossopharyngeal and vagus nerves, which affects swallowing and the risk of aspiration.
B. Withholding oral fluids or foods is crucial because impaired function of these cranial nerves increases the risk of aspiration and can lead to choking or pneumonia, making this the priority action.
C. Speaking clearly while facing the client is a good communication practice but does not address the immediate concern of impaired swallowing and risk of aspiration.
D. Applying artificial tears is important for protecting the cornea, but it is not directly related to the functions of CN IX and CN X or the immediate management of swallowing difficulties.

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Correct Answer is B

Explanation

A. An otoscope is used to examine the ear canal and tympanic membrane, not to assess cranial nerve III. This tool is more relevant for assessing cranial nerve VIII (vestibulocochlear), which is responsible for hearing and balance.
B. A penlight is used to assess CN III (oculomotor) by evaluating the pupil's response to light and the ability to move the eye. This nerve controls most of the eye's movements, including constriction of the pupil in response to light.
C. A cotton ball is used to test the sensory function of cranial nerve V (trigeminal), which is responsible for facial sensation. It is not used for assessing CN III.
D. Lavender or other scents may be used to test CN I (olfactory), responsible for the sense of smell, but it is not related to CN III, which governs eye movements and pupil reactions.

A. Limiting visits by family members and friends B. Assessment of amylase and lipase C. Abdominal assessment including abdominal girth D. Continuous cardiac monitoring

Correct Answer is C

Explanation

A. Limiting visits by family members and friends is not necessary for managing ascites and could hinder the client's emotional support.
B. While amylase and lipase are important in assessing pancreatic function, they are not directly relevant to ascites management or liver cancer.
C. An abdominal assessment including abdominal girth is crucial for monitoring ascites, as changes in girth can indicate fluid accumulation or changes in the client's condition.
D. Continuous cardiac monitoring is not typically indicated for clients with liver cancer experiencing ascites unless there are specific cardiac concerns.

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The neurologic assessment of a patient indicates impaired function of the glossopharyngeal (CN IX) and the vagus nerve (CN X). Based on these findings the nurse plans to:

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Naxlex Comprehensive Predictor Exams

The nurse prepares to assess the patient's cranial nerves. Which tool is necessary to assess cranial nerve (CN) III (oculomotor)?

Correct Answer is B

Explanation

The nurse is planning care for the client diagnosed with liver cancer experiencing ascites. The nurse would include which of the following?

Correct Answer is C

Explanation

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