The nurse is preparing to assess the motor function of the client's trigeminal nerve. Which of the following tests would be most appropriate for the nurse to use?

Have the client smile, frown, and puff out their cheeks

Palpate the masseter muscles when the client clenches their teeth

Assess constriction of the client's pupils with direct and indirect light

Ask the patient to turn their head left and right with resistance

Answer and Explanation

The Correct Answer is B

A) Have the client smile, frown, and puff out their cheeks: This test assesses the facial nerve (cranial nerve VII), not the trigeminal nerve (cranial nerve V). While important for evaluating facial movement, it does not specifically test the motor function of the trigeminal nerve, which is responsible for mastication.

B) Palpate the masseter muscles when the client clenches their teeth: This is the correct test for assessing the motor function of the trigeminal nerve. The trigeminal nerve innervates the muscles responsible for chewing, and palpating the masseter muscles during clenching allows the nurse to evaluate muscle strength and function. It provides insight into the motor capabilities associated with this cranial nerve.

C) Assess constriction of the client's pupils with direct and indirect light: This test evaluates the function of the optic nerve (cranial nerve II) and the oculomotor nerve (cranial nerve III). It does not assess the trigeminal nerve and is not relevant for this assessment.

D) Ask the patient to turn their head left and right with resistance: This action tests the spinal accessory nerve (cranial nerve XI), which is involved in neck movement. It does not relate to the function of the trigeminal nerve, making it an inappropriate choice for this specific assessment.

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Correct Answer is C

Explanation

A) "The client may be having a cardiac event": While this statement indicates a potential concern, it lacks specific details about the client's current condition. It suggests a possibility but does not clearly communicate the immediate issue or symptoms being experienced.

B) "The client needs an EKG. Please see her immediately": This statement expresses urgency and a request for action but does not provide the necessary context or information about the client's symptoms. It is more aligned with the "Request" part of SBAR rather than the "Situation."

C) "The client is experiencing chest pain and shortness of breath": This statement accurately describes the current situation the client is facing. It provides essential information regarding the symptoms the nurse is observing, making it a clear example of the "Situation" in the SBAR framework. This information is critical for the provider to understand the urgency of the situation.

D) "The client's admitting diagnosis is stage 2 breast cancer": While this statement provides important background information, it does not reflect the immediate situation that requires attention. It does not address the current health issue that is prompting the nurse to contact the provider.

A. Range of motion B. Color C. Fine motor assessment by having client touch each finger to thumb D. Pain assessment E. Pulses intact

Correct Answer is ["B","C","D","E"]

Explanation

A) Range of motion: While assessing range of motion can provide information about joint function, it is not a specific component of a peripheral vascular assessment. This assessment primarily focuses on circulation and vascular integrity rather than mobility.

B) Color: Assessing the color of the upper extremities is essential in a peripheral vascular assessment. Changes in color can indicate issues such as poor circulation, hypoxia, or vascular disease, making it a critical observation.

C) Fine motor assessment by having the client touch each finger to thumb: This assessment evaluates both coordination and dexterity, which can indicate adequate blood flow to the fingers and upper extremities. It helps to assess the functional capacity of the hands in relation to vascular health.

D) Pain assessment: Evaluating for pain in the upper extremities is important, as pain can be a sign of vascular problems, including conditions like peripheral artery disease. It provides insight into the presence of ischemia or other vascular issues.

E) Pulses intact: Assessing the pulses in the upper extremities is a key component of a peripheral vascular assessment. Palpating the radial and brachial pulses helps determine blood flow and vascular function in the arms.

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The nurse is preparing to assess the motor function of the client's trigeminal nerve. Which of the following tests would be most appropriate for the nurse to use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is ["B","C","D","E"]

Explanation

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