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: The base of the skull houses occipital nodes, not submental ones, which drain the lower face. Palpating here misses the submental region, irrelevant to sinus or throat infections, misaligning with lymphatic drainage patterns in this case.

Choice B reason: The angle of the jaw targets submandibular nodes, not submental, which sit midline under the chin. This area drains the jaw and mouth but not specifically the submental zone tied to the client’s symptoms directly.

Choice C reason: Behind the chin tip is the submental node location, draining the lower lip, tongue, and anterior mouth. With sinus and throat infection, this spot is key for detecting lymphadenopathy linked to the client’s fever and elevated WBC.

Choice D reason: Behind the ears assesses postauricular nodes, unrelated to submental drainage of the chin and mouth. This misses the infection’s likely lymphatic response, focusing on a region not typically involved in sinus or throat pathology here.

A. Acute otitis media B. Serous otitis media C. Scarring from previous infections D. Intact tympanic membrane

Correct Answer is D

Explanation

Choice A reason: Acute otitis media shows a red, bulging tympanic membrane due to bacterial infection and pus. A pearly gray, shiny appearance contrasts this, indicating no acute inflammation or fluid, ruling out this active middle ear condition entirely.

Choice B reason: Serous otitis media presents with amber fluid behind a retracted or neutral tympanic membrane, not pearly gray and shiny. This suggests no sterile effusion, distinguishing it from the normal, healthy membrane observed in this inspection clearly.

Choice C reason: Scarring from past infections appears as white, opaque patches on the tympanic membrane, not uniform pearly gray shininess. This finding lacks the irregular, thickened look of scar tissue, pointing to an unscathed membrane instead here.

Choice D reason: A pearly gray, shiny tympanic membrane is normal, reflecting light off an intact, healthy eardrum. This lacks signs of infection or fluid, aligning with standard anatomy where the membrane’s cone of light confirms its integrity fully.

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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

Correct Answer is C

Explanation

While inspecting the tympanic membrane the nurse notes a pearly gray and shiny appearance. What would this finding indicate?

Correct Answer is D

Explanation

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