The nurse is assessing cranial nerve 5 (the trigeminal nerve) in a newly admitted client. What instruction should the nurse provide to the client during this phase of the assessment?

"Clench your teeth together tightly."

"Open your mouth wide and say 'ah.'"

"Look at me while I shine this light in your eye."

"Close your left eye and look at me with your right eye."

Answer and Explanation

The Correct Answer is A

Choice A reason: Clenching teeth tests cranial nerve V’s motor branch, innervating mastication muscles like the masseter. This assesses strength and symmetry, directly evaluating trigeminal function, making it the precise instruction for this nerve’s motor assessment accurately here.
Choice B reason: Opening the mouth and saying “ah” tests cranial nerves IX and X, not V. This assesses gag reflex and palate movement, missing the trigeminal’s role in jaw strength, rendering it irrelevant to this specific nerve exam fully.
Choice C reason: Shining light in the eye tests cranial nerves II and III, not V. This checks pupil response, unrelated to trigeminal sensory or motor functions, excluding it from the assessment of jaw and facial sensation entirely here.
Choice D reason: Closing one eye and looking tests cranial nerves III, IV, and VI, not V. This evaluates eye movement, not trigeminal innervation of facial muscles or sensation, disconnecting it from the intended cranial nerve assessment fully here.

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Correct Answer is D

Explanation

Choice A reason: Turbulence in large airways causes coarse sounds, not high-pitched wheezes. Wheezes stem from narrowed smaller passages, like bronchioles, not broad airway dynamics, making this less accurate for the specific sound’s pathophysiology fully here.
Choice B reason: Air leaking into the pleural space (pneumothorax) reduces breath sounds, not causing wheezes. Wheezes arise from airway narrowing, not alveolar rupture, excluding this as the source of the auscultated adventitious sound entirely here fully.
Choice C reason: Air diversion from trachea to bronchi is normal airflow, not producing wheezes. Wheezes require obstruction or constriction in smaller airways, not tracheal branching, rendering this unrelated to the sound’s pathological origin comprehensively here.
Choice D reason: Wheezes result from constricted respiratory passages, like in asthma, where narrowed bronchioles vibrate with airflow. This high-pitched sound matches the pathophysiology of airway narrowing, making it the correct explanation for this finding accurately here.

A. "Are there any foods that you cannot eat?" B. "What have you eaten in the last 24 hours?" C. "Are any members of your family obese?" D. "How many meals do you eat each day?"

Correct Answer is B

Explanation

Choice A reason: Food restrictions identify allergies or preferences, but not intake patterns. This limits nutritional status insight, missing recent consumption data critical for assessing current health, making it less foundational for this initial evaluation fully here.
Choice B reason: A 24-hour recall details recent intake, offering a snapshot of diet quality and quantity. This directly informs nutritional status, habits, and deficits, making it the most appropriate starting question for a comprehensive assessment accurately here.
Choice C reason: Family obesity history suggests genetic risk, not the client’s nutrition. This indirect data lacks specificity on current intake, rendering it less useful than a direct dietary recall for this nutritional assessment entirely and fully here.
Choice D reason: Meal frequency provides structure, not content or quality. It’s less informative than a 24-hour recall, which captures specifics of what’s eaten, making it secondary for initiating a detailed nutritional evaluation comprehensively here fully.

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The nurse is assessing cranial nerve 5 (the trigeminal nerve) in a newly admitted client. What instruction should the nurse provide to the client during this phase of the assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiologic process in the lungs?

Correct Answer is D

Explanation

The nurse is preparing to perform a nutritional assessment of a newly admitted client. What question would be most appropriate for the nurse to ask when initiating the assessment?

Correct Answer is B

Explanation

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