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 B

Explanation

A. May show evidence of some clouding of his level of consciousness: While patients who have been in intensive care for an extended period may experience some clouding of consciousness or altered mental status, it is not a universal finding. This option implies a more significant alteration in consciousness than typically expected in a patient transitioning to a medical-surgical unit.

B. Will be oriented to place and person, but the patient may not be certain of the date: This is a common expectation for patients who have been in an intensive care setting for a prolonged period. They may maintain orientation to person and place due to their familiarity with the environment and staff, but they might have difficulty recalling the date due to the stress of hospitalization and changes in routine.

C. Disruptive behavior: While some patients may exhibit changes in behavior after a long stay in intensive care, it is not a standard expectation. Many patients may be more subdued and fatigued rather than disruptive.

D. Will state, "I am so relieved to be out of intensive care": While this response might occur, it is not guaranteed. Patients may have mixed emotions about their transition from intensive care, including anxiety or confusion. Therefore, this statement is not a definitive expectation during the mental status examination.

A. Changes in peripheral vision in response to bright light B. Pupillary dilation when looking at a near object C. Pupillary constriction when looking at a near object D. involuntary blinking in the presence of bright light

Correct Answer is C

Explanation

A. Changes in peripheral vision in response to bright light: This assessment relates more to visual field testing and does not evaluate accommodation. Accommodation specifically involves the ability of the eye to focus on near objects.

B. Pupillary dilation when looking at a near object: Pupillary dilation occurs when focusing on distant objects due to decreased light and increased depth of focus, not during accommodation.

C. Pupillary constriction when looking at a near object: This is the correct assessment for visual accommodation. When a person looks at a near object, the pupils constrict to enhance focus and reduce light entry, aiding in clearer vision of nearby objects. This reaction is part of the accommodation reflex, which also involves changes in lens shape.

D. Involuntary blinking in the presence of bright light: This response is known as the photo pupillary reflex, which involves blinking in reaction to bright light but does not assess accommodation. Accommodation specifically evaluates the eye's ability to focus on objects at different distances.

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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

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Naxlex Comprehensive Predictor Exams

A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. What should the nurse expect during this patient's tests of cognitive function?

Correct Answer is B

Explanation

The nurse is testing a patient's visual accommodation. How is accommodation assessed?

Correct Answer is C

Explanation

A patient's laboratory data reveal an elevated thyroxine (T4) level. What gland should the nurse assess?

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The nurse is performing the diagnostic positions test (6 Cardinal Gazes). Which result is a normal finding?

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The nurse is observing the auscultation technique of a student nurse. What is the correct method to use when progressing from one auscultatory site on the thorax to another?

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

The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?