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
II
VI
III
IV
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Ethmoid: The ethmoid sinuses are located between the eyes and are not typically accessible for palpation during a physical examination. Instead, tenderness in this area is assessed through inspection and indirect methods rather than direct palpation.
B. Maxillary: The maxillary sinuses are located in the cheeks and are accessible for palpation. The nurse can assess for tenderness or swelling in this area, which can indicate sinusitis or infection. Palpating the maxillary sinuses is a standard part of the examination for patients with cold and sinus pain.
C. Mastoid: The mastoid process is located behind the ear and contains air cells, but it is not directly involved in sinus pain associated with cold symptoms. While mastoid tenderness may indicate a different type of infection (such as mastoiditis), it is not part of the sinus assessment.
D. Sphenoid: The sphenoid sinuses are located deep within the skull, behind the nasal cavity, and are not accessible for palpation during a physical examination. Any issues with the sphenoid sinuses would typically be assessed through imaging studies rather than physical palpation.
Correct Answer is B
Explanation
A. Palm: The palm of the hand is not ideal for palpating lymph nodes because it does not provide the fine sensitivity needed to detect subtle differences in size, texture, and tenderness.
B. Pads of fingers: The pads of the fingers are the best part of the hand to use when examining lymph nodes. This part allows for precise and gentle palpation, helping the nurse assess the size, consistency, and mobility of the lymph nodes effectively.
C. Base of hand: The base of the hand is less sensitive and not suitable for palpating lymph nodes as it provides less sensitivity compared to the pads of the fingers. The base of the hand is better suited for applying pressure during broader palpation techniques It does not provide the necessary tactile feedback for a thorough examination.
D. Ulnar surface: The ulnar surface of the hand is not typically used for palpation of lymph nodes. It is less sensitive compared to the pads of the fingers and is not appropriate for this examination.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.