The nurse is assessing cranial nerves 3, 4 and 6 (oculomotor, trochlear and abducens). Which technique might the nurse use to assess all three in one technique?

Use an ophthalmoscope to view the optic disc and retina.

Have the client move his eyes in the 6 cardinal fields of gaze.

Use a tuning fork to see if the client can sense vibration on the closed eyelids bilaterally.

Have the client turn his head to track the nurse's hand movement as it makes a 360 curve around the client's head.

Answer and Explanation

The Correct Answer is B

Choice A reason: Ophthalmoscopy checks cranial nerve II (optic), not III, IV, or VI. It visualizes the retina, missing the eye movement control these nerves govern, making it irrelevant to their motor function assessment entirely here fully.
Choice B reason: The 6 cardinal fields test cranial nerves III (eye movement, pupil), IV (superior oblique), and VI (lateral rectus). This single technique evaluates all three by tracking coordinated eye motion, making it the most efficient method accurately here.
Choice C reason: Vibration on eyelids tests sensation, possibly cranial nerve V, not III, IV, or VI. These nerves control eye movement, not sensory input, excluding this from assessing their motor roles in this neurological exam fully here.
Choice D reason: Head turning with hand tracking involves neck muscles and possibly cranial nerve XI, not just III, IV, VI. This dilutes focus on eye-specific movements, making it less precise for these cranial nerves’ assessment entirely here.

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Correct Answer is C

Explanation

Choice A reason: Convergent response isn’t a standard term; convergence occurs with near focus, not light. This misnames the pupil constriction in the opposite eye from light stimulus, unrelated to the observed cranial nerve III reflex entirely here.
Choice B reason: Direct reflex is pupil constriction in the lit eye, not the other. This describes the same-side reaction, not the contralateral constriction observed, distinguishing it from the finding in this eye exam fully and accurately here.
Choice C reason: Consensual response is when light in one eye constricts the other’s pupil, via cranial nerve III. This matches the finding, reflecting normal optic and oculomotor nerve interplay, making it the precise description comprehensively here.
Choice D reason: Accommodation adjusts focus for near vision, constricting pupils bilaterally, not from unilateral light. This involves lens change, not the light-induced contralateral reflex seen, excluding it as the correct term in this scenario fully here.

A. Increased air turbulence in the large airways. B. Air leaking from the alveoli into the pleural space. C. Air diverting from the trachea to the bronchi. D. Constriction of the respiratory passages.

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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The nurse is assessing cranial nerves 3, 4 and 6 (oculomotor, trochlear and abducens). Which technique might the nurse use to assess all three in one technique?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing a full assessment for their client on a telemetry unit. During the eye exam, a nurse shines a light into one of the client's eyes and the pupil of the other eye constricts. What is the most appropriate description of this finding?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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