The nurse read the patient's health history and noted cranial nerve III oculomotor paralysis. Which of the following would the nurse expect?
The eye cannot look to the outside.
Myopia.
Ptosis will be evident and no pupillary constriction.
Normal eye movement.
The Correct Answer is C
Choice a reason:
The inability of the eye to look outward, known as lateral rectus palsy, is associated with cranial nerve VI, the abducens nerve, not the oculomotor nerve. The oculomotor nerve does not control the lateral rectus muscle which governs this movement.
Choice b reason:
Myopia, or nearsightedness, is a refractive error of the eye where distant objects appear blurry while close objects can be seen clearly. It is not related to oculomotor nerve paralysis, which affects eye movements and pupil response, not the shape of the eyeball or the refractive properties of the lens.
Choice c reason:
Ptosis, or drooping of the upper eyelid, and an absence of pupillary constriction are classic signs of oculomotor nerve paralysis. The oculomotor nerve controls most of the eye's movements, including lifting the eyelid via the levator palpebrae superioris muscle and constricting the pupil through the circular muscles of the iris.
Choice d reason:
Normal eye movement would not be expected in a patient with oculomotor nerve paralysis. This nerve controls the majority of the eye's movements, so paralysis would lead to abnormal eye movement, such as the inability to move the eye upward, downward, or inward.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Tracheal sounds are harsh, high-pitched breath sounds typically heard over the trachea in the neck. They are not expected to be heard over the peripheral lung fields of a young adult during a routine lung auscultation.
Choice B Reason:
Vesicular breath sounds are the normal sounds heard over most of the lung fields. They are characterized by a soft, low-pitched, rustling sound during inhalation and are softer during exhalation. These sounds are created by air moving through the smaller airways such as the bronchioles and alveoli.
Choice C Reason:
Bronchovesicular sounds are heard over the major bronchi and are characterized by a moderate pitch and intensity. They are typically heard between the first and second intercostal spaces at the sternal border anteriorly and between the scapulae posteriorly, not over most of the lung fields.
Choice D Reason:
Bronchial breath sounds are high-pitched and louder than vesicular sounds, with a hollow quality, and are normally heard over the manubrium. If heard over the peripheral lung fields, they may indicate lung consolidation or other abnormalities.
Correct Answer is A
Explanation
Choice A reason:
A formal hearing test, or audiometry, is the most comprehensive method for assessing hearing loss, which can be a side effect of ototoxic medications. These tests can detect both conductive and sensorineural hearing loss, providing a detailed profile of hearing function across different frequencies. For clients receiving ototoxic antibiotics, regular monitoring through formal hearing tests is recommended to detect any early signs of hearing impairment and to implement timely interventions.
Choice B reason:
The rubbing fingers test is a rudimentary hearing screening method where the examiner rubs their fingers together near the patient's ear, asking them to indicate when they hear the sound. While this test can be used as a quick check for hearing loss, it is not as sensitive or specific as formal audiometry and may not detect early or mild hearing loss caused by ototoxic drugs.
Choice C reason:
Tuning fork tests, such as the Weber and Rinne tests, are used to differentiate between conductive and sensorineural hearing loss. These tests can be useful in a clinical setting to provide immediate information about the type of hearing loss; however, they are not as comprehensive as formal hearing tests and may not be sufficient for monitoring ototoxicity.
Choice D reason:
The whisper hearing test involves the examiner whispering words or numbers and asking the patient to repeat them. This test can be useful for detecting significant hearing loss but may not be sensitive enough to detect the early stages of ototoxicity. Moreover, the test's accuracy can be affected by the examiner's voice level and the testing environment.
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