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 B
Explanation
Pain is a subjective experience, and the client's report of pain should be respected and addressed promptly. If the pain medication is ordered and it has been longer than the ordered interval, the nurse should administer the medication as prescribed. In general, withholding pain medication for a client in pain is not an appropriate action.
Administering half the ordered dose of pain medication without a healthcare provider's order is also not appropriate. The nurse should follow the healthcare provider's orders for pain medication administration and titration.
It's also not appropriate to assume that the client is faking pain without adequate assessment and evidence to support such a claim. The nurse should perform a thorough pain assessment, including the location, intensity, and quality of the pain, and consider non-pharmacological interventions to help manage the pain.
Correct Answer is D
Explanation
Nurses are mandated reporters, meaning they are legally required to report any suspected or confirmed cases of child, elder, or vulnerable adult abuse or neglect to the appropriate authorities, such as child protective services or adult protective services. This duty applies regardless of whether the abuse or neglect was disclosed by the victim or observed by the nurse.
While nurses may choose to involve family members or refer the individual to social services, these actions do not replace the legal obligation to report abuse or neglect. Failure to report can result in legal and professional consequences for the nurse.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today