The nurse is assessing a patient's nostrils for patency. How should the nurse best perform this assessment?
Insert a nasal tube into each nostril to ensure no blockage is present.
Refer patient to a nasal specialist to ensure there is not any blockage in the nasal cavity.
Press each nostril shut and have the patient sniff to ensure air passage through each nostril.
Have the patient blow their nose into a tissue forcefully.
The Correct Answer is C
A. Insert a nasal tube into each nostril to ensure no blockage is present: Inserting a nasal tube is an invasive procedure that is not necessary for assessing nostril patency. This method can cause discomfort and does not provide a simple or effective assessment of airflow through the nostrils.
B. Refer patient to a nasal specialist to ensure there is not any blockage in the nasal cavity: Referral to a specialist is unnecessary for a basic assessment of nostril patency. The nurse can perform a simple, non-invasive test before considering a referral for further evaluation.
C. Press each nostril shut and have the patient sniff to ensure air passage through each nostril: This method effectively assesses nostril patency. By occluding one nostril at a time, the nurse can evaluate airflow and determine if there is any blockage or obstruction in the nasal passages. It is a quick and straightforward assessment technique.
D. Have the patient blow their nose into a tissue forcefully: Asking the patient to blow their nose can provide information about mucus presence or drainage but does not specifically assess nostril patency. This action may also cause discomfort and is not the best initial assessment for airflow through the nostrils.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. VIII: Cranial nerve VIII, also known as the vestibulocochlear nerve, is responsible for transmitting auditory information from the cochlea of the inner ear to the brain, allowing for the perception of sound. It also plays a role in balance by carrying information from the vestibular apparatus regarding head position and movement.
B. VI: Cranial nerve VI, the abducens nerve, controls the lateral rectus muscle, which is responsible for outward eye movement. It does not have any function related to hearing.
C. V: Cranial nerve V, the trigeminal nerve, is primarily responsible for sensation in the face and motor functions such as biting and chewing. It does not conduct nerve impulses related to hearing.
D. VII: Cranial nerve VII, the facial nerve, controls muscles of facial expression and carries taste sensations from the anterior two-thirds of the tongue. While it has some minor roles in the auditory system (such as innervating the stapedius muscle), it is not primarily responsible for conducting nerve impulses related to hearing.
Correct Answer is C
Explanation
A. Bell palsy: Bell palsy is characterized by sudden, unilateral facial weakness or paralysis, usually affecting one side of the face. While it can impact sensation, the inability to differentiate between sharp and dull stimuli on both sides of the face suggests a more systemic issue rather than just Bell palsy.
B. Scleroderma: Scleroderma is a systemic autoimmune disease that affects connective tissue, leading to skin thickening and changes in blood flow. While it can cause skin changes and discomfort, it does not specifically result in the loss of the ability to differentiate sharp and dull sensations in a localized manner.
C. Damage to the trigeminal nerves: The trigeminal nerve (cranial nerve V) is responsible for sensory perception in the face, including the ability to differentiate between sharp and dull sensations. Damage to this nerve can lead to loss of sensation or altered sensation in the facial region. The bilateral nature of the symptoms suggests a central or systemic cause affecting the trigeminal pathways.
D. Frostbite with resultant paresthesia to the cheeks: Frostbite typically causes localized tissue damage and would more likely present with symptoms specific to the affected areas, such as numbness, discoloration, or blistering. While frostbite can lead to sensory changes, it would not typically result in a generalized inability to differentiate sensations on both sides of the face.
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