The nurse is assessing the 6 stages of cardinal gaze. This test assesses:
Cranial nerves III, IV, and X for eye muscle strength.
Cranial nerves III, IV, and VI for ocular motor movements.
Cranial nerves IV, V and VII for visual accuracy.
Cranial nerve II for visual acuity.
The Correct Answer is B
The nurse is assessing the 6 stages of the cardinal gaze to evaluate the function of the cranial nerves III, IV, and VI for ocular motor movements, which control eye movement and positioning.
Cranial nerve III controls the superior rectus, inferior rectus, and medial rectus muscles, which move the eye up, down, and inward, respectively. Cranial nerve IV controls the superior oblique muscle, which moves the eye downward and laterally. Cranial nerve VI controls the lateral rectus muscle, which moves the eye outward.
Therefore, the nurse will observe the patient's ability to move their eyes smoothly in each of the six cardinal positions of gaze and note any abnormalities that may indicate dysfunction of these cranial nerves. This test is used to diagnose conditions such as strabismus, nystagmus, and palsy of the ocular motor nerves.
Cranial nerve II, on the other hand, is responsible for visual acuity, not eye movement, and is tested separately using a visual acuity chart or other vision tests.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When a patient is admitted with a complaint of chest pain, the priority assessment would be to determine whether the patient is experiencing an acute cardiac event, such as a heart attack. This would involve a comprehensive assessment that includes obtaining the patient's medical history, vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation), performing a physical exam, and obtaining an electrocardiogram (ECG).
Other important factors to assess include the location and nature of the pain, any associated symptoms (such as shortness of breath or diaphoresis), the patient's current medications and medical history (including any history of heart disease or risk factors), and any recent procedures or interventions that may have led to the current presentation.
Prompt assessment and intervention are crucial in managing a patient with chest pain, as timely treatment can help to minimize damage to the heart muscle and prevent further complications. Therefore, any signs of an acute cardiac event should be immediately reported to the healthcare provider in charge, and appropriate interventions should be initiated promptly.
Correct Answer is B
Explanation
The nurse will document the patient's chest pains that move down her left arm as radiating pain. Radiating pain is a type of pain that starts at a specific point and spreads outwards to other areas of the body. In this case, the pain starts in the chest and moves down the left arm, which is a common symptom of cardiac or heart-related issues. Phantom pain is a type of pain that is perceived to be present in a body part that has been amputated or lost. Referred pain is pain that is felt in a different part of the body from where the actual problem is located. Somatic pain is pain that arises from the skin, muscles, bones, or connective tissues.
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