The nurse performs that technique shown when assessing the client. What cranial nerve is the nurse assessing?

XII

VII

Answer and Explanation

The Correct Answer is C

A. XII: Cranial nerve XII (hypoglossal) controls tongue movements, but is not typically assessed by the technique described.

B. V: Cranial nerve V (trigeminal) is assessed for facial sensation and mastication, not the technique in question.

C. VII: Cranial nerve VII (facial) is responsible for facial expressions and is assessed by asking the client to perform various facial movements.

D. XI: Cranial nerve XI (accessory) is involved in shoulder and neck movements, not facial expressions.

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Correct Answer is A

Explanation

A. History of present illness: The OLD CART mnemonic is used to evaluate the characteristics of a symptom, which is documented under the history of present illness.

B. Initial Information: This section includes basic demographic and background information rather than detailed symptom analysis.

C. Review of Systems: This section includes a systematic review of body systems and their functions, not the detailed attributes of a specific symptom.

D. Health Patterns: This section covers the client’s overall health patterns and lifestyle but not the detailed attributes of a specific symptom.

A. Moist nasal mucosa B. Cerumen in the ear C. Enlarged lymph node in the neck D. Acne lesions on the face and upper chest

Correct Answer is C

Explanation

A. Moist nasal mucosa: This is generally a normal finding and does not usually require immediate follow-up unless there are other symptoms suggesting infection or other issues.

B. Cerumen in the ear: While cerumen can impact hearing, it is typically not an urgent issue and can be managed with appropriate ear care.

C. Enlarged lymph node in the neck: Enlarged lymph nodes can indicate an underlying infection or malignancy, especially if persistent or accompanied by other symptoms, thus requiring immediate follow-up.

D. Acne lesions on the face and upper chest: Acne is common and usually not an urgent concern unless it is severe or causing significant distress.

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The nurse performs that technique shown when assessing the client. What cranial nerve is the nurse assessing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the seven attributes of a client's symptom using the mnemonic OLD CART. In which section of the comprehensive health history will the nurse document this information?

Correct Answer is A

Explanation

When the nurse collects objective data, which finding requires immediate follow-up?

Correct Answer is C

Explanation

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