The nurse is examining an elderly client and notes an exaggerated curvature of the thoracic spine.
The nurse should document this finding as which of the following?

Choice A rationale

The abducens cranial nerve (CN VI) controls the lateral rectus muscle of the eye, which is responsible for outward movement. It is not assessed using the Snellen visual acuity chart. The function of this nerve is tested through the evaluation of lateral eye movements.

Choice B rationale

The optic cranial nerve (CN II) is responsible for vision, including visual acuity and visual fields. It is assessed using the Snellen visual acuity chart to determine how well a person can see at various distances. This test evaluates the clarity and sharpness of vision, making CN II the correct answer.

Choice C rationale

The trochlear cranial nerve (CN IV) controls the superior oblique muscle, which helps with downward and inward eye movements. It is not assessed using the Snellen visual acuity chart but rather through the evaluation of eye movements and alignment.

Choice D rationale

The oculomotor cranial nerve (CN III) controls most of the eye's movements, including those of the superior, inferior, and medial rectus muscles, as well as the inferior oblique muscle. It is also responsible for controlling the pupil's response to light. The Snellen visual acuity chart does not assess the function of CN III, as it focuses on visual clarity and acuity.

Choice A rationale

Rhonchi are low-pitched, continuous breath sounds that are often indicative of secretions in the large airways. These sounds may change or clear with coughing, so the nurse should have the patient cough and then auscultate again to reassess the presence of rhonchi.

Choice B rationale

Wheezes are high-pitched, musical sounds heard primarily during expiration. They are caused by narrowed airways, typically due to asthma or other obstructive lung conditions. Wheezes do not usually clear with coughing and require specific treatments to address airway constriction.

Choice C rationale

Crackles are discontinuous, popping sounds heard during inspiration and are associated with fluid in the alveoli, such as in conditions like pneumonia or heart failure. Crackles are not typically cleared by coughing and may persist despite the patient's efforts to clear their airways.

Choice D rationale

Stridor is a high-pitched, harsh sound heard during inspiration, often indicating upper airway obstruction. Stridor is a medical emergency and requires immediate intervention to secure the airway. It does not clear with coughing and signifies a critical respiratory issue. .