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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Syphilitic chancre is a painless ulcer, not itchy with white discharge. This STD lacks the erythematous, swollen, thick discharge presentation, excluding it from matching the client’s vaginal symptoms entirely and accurately in this case here.
Choice B reason: Trichomoniasis causes frothy, yellow-green discharge with itching, not thick white. This parasitic infection’s discharge differs from the observed curd-like consistency, making it less likely than candidiasis for this clinical picture fully here.
Choice C reason: Bacterial vaginosis produces thin, gray discharge with fishy odor, not thick white or intense itching. This bacterial imbalance contrasts with the erythematous, swollen findings, ruling it out as the suspected condition comprehensively here.
Choice D reason: Candidal vaginitis, from yeast, causes thick, white, curd-like discharge, itching, and erythema. This matches the client’s swollen labia and mucosal redness, making it the most likely diagnosis for these vaginal symptoms accurately here fully.
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.
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