The nurse is assessing a 12 year old with new onset of double vision. The nurse notes the child's right eye is positioned down and out. The nurse knows these findings are suggestive of damage to cranial nerve

III

Answer and Explanation

The Correct Answer is C

A. II: The optic nerve (cranial nerve II) is responsible for vision, including visual acuity and the afferent limb of the pupillary reflex. Damage to this nerve causes vision loss or visual field defects but does not affect eye movement or positioning.

B. VI: The abducens nerve (cranial nerve VI) innervates the lateral rectus muscle, which abducts the eye. Damage to this nerve results in an inability to move the eye laterally, leading to horizontal diplopia, but it does not cause a "down and out" eye position.

C. III: The oculomotor nerve (cranial nerve III) controls most of the extraocular muscles, including the superior, inferior, and medial rectus muscles, as well as the inferior oblique. It also controls the levator palpebrae superioris and the parasympathetic fibers responsible for pupillary constriction. Damage to cranial nerve III results in ptosis, a "down and out" eye position due to unopposed action of the lateral rectus (cranial nerve VI) and superior oblique (cranial nerve IV), and potentially a dilated pupil.

D. IV: The trochlear nerve (cranial nerve IV) innervates the superior oblique muscle, which depresses and internally rotates the eye. Damage to this nerve typically causes vertical diplopia and difficulty looking downward, especially when reading or descending stairs, but it does not cause a "down and out" eye position at rest.

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Correct Answer is D

Explanation

A. Thought content: The four unrelated words test does not assess thought content, which refers to the patient’s ideas, beliefs, and perception of reality. Thought content is typically evaluated through direct questioning and observation of the patient’s speech patterns and behaviors.

B. Attention span: Attention span is assessed by evaluating the patient's ability to concentrate on simple tasks, such as following a set of instructions or completing a short mental exercise. The four unrelated words test is not designed to measure attention span directly.

C. Distant memory: Distant memory refers to the recall of events or information from the past, such as childhood experiences or historical events. The four unrelated words test assesses recent recall rather than distant memory.

D. New memory: The four unrelated words test evaluates the ability to form and retrieve new memories. The nurse provides the patient with four unrelated words, asks them to recall them after a few minutes, and reassesses recall at intervals. Impairments in new memory recall can indicate cognitive deficits seen in conditions like dementia or head trauma.

A. Rubella B. Leukoplakia C. Rheumatic fever D. Scarlet fever

Correct Answer is C

Explanation

A. Rubella: Rubella is a viral infection caused by the rubella virus, not a complication of untreated strep throat. It is unrelated to Group A Streptococcus (GAS) infection and is prevented through vaccination.

B. Leukoplakia: Leukoplakia is a condition characterized by white patches on the mucous membranes, often associated with chronic irritation or tobacco use. It is not a complication of streptococcal pharyngitis.

C. Rheumatic fever: Untreated streptococcal throat infections caused by Group A Streptococcus can lead to rheumatic fever, an inflammatory disease affecting the heart, joints, skin, and brain. This autoimmune response can result in rheumatic heart disease, which may cause permanent cardiac damage.

D. Scarlet fever: While scarlet fever can develop from strep throat, it is not a long-term complication but rather an acute reaction to the streptococcal toxin. The more serious complication of untreated strep throat is rheumatic fever, which can have lasting consequences, particularly for the heart.

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The nurse is assessing a 12 year old with new onset of double vision. The nurse notes the child's right eye is positioned down and out. The nurse knows these findings are suggestive of damage to cranial nerve

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse understands that the four unrelated words test provides information related to which cognitive function?

Correct Answer is D

Explanation

A patient has been diagnosed with strep throat. The nurse is aware that without treatment, which complication may occur?

Correct Answer is C

Explanation

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