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 D

Explanation

A) Occurs only in the clinical area: Focused assessments can be conducted in various settings, including outpatient clinics, home health visits, and emergency departments. Thus, this statement does not accurately define the difference.

B) Involves all body systems: A focused assessment is specifically targeted and does not involve an evaluation of all body systems. Instead, it concentrates on particular areas of concern, making this statement incorrect.
C) Covers the body from head to toe: This describes a comprehensive assessment rather than a focused one. A comprehensive assessment is thorough and covers the entire body, while a focused assessment zeroes in on specific issues or symptoms.

D) More in depth on specific issues: A focused assessment is designed to gather detailed information about particular health problems or concerns rather than providing a broad overview of the patient’s overall health. This targeted approach allows healthcare providers to identify and address specific needs effectively, making this the correct choice.

A. Third left ICS B. Second right ICS C. Fourth left ICS D. Second left ICS

Correct Answer is C

Explanation

A) Third left ICS: The third left intercostal space (ICS) is typically associated with the auscultation of the pulmonic valve rather than the tricuspid valve. While it is in the vicinity of the heart, it is not the correct location for assessing the tricuspid area.

B) Second right ICS: The second right intercostal space is where the aortic valve is best heard. This location is important for assessing blood flow through the aorta, but it is not relevant for the tricuspid valve auscultation.

C) Fourth left ICS: The tricuspid valve is best auscultated at the fourth left intercostal space along the left sternal border. This area allows for optimal listening to the sounds produced by the tricuspid valve, providing important information about right heart function.

D) Second left ICS: The second left intercostal space is the auscultation point for the pulmonic valve, not the tricuspid valve. While this area is critical for assessing the heart, it does not correspond to the location for the tricuspid valve.

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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

What makes a focused assessment different from a comprehensive assessment?

Correct Answer is D

Explanation

The nurse knows to auscultate the tricuspid valve at which location?

Correct Answer is C

Explanation

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