The nurse read the patient's health history cranial nerve III oculomotor paralysis. Which of the following would the nurse expect?

Муоріа

Normal eye movement

Ptosis will be evident and no pupillary constriction.

The eye cannot look to the outside side.

Answer and Explanation

The Correct Answer is C

(a) Mydriasis:

While mydriasis (dilated pupil) can be associated with cranial nerve III damage, it does not fully describe the range of symptoms expected with oculomotor paralysis. Cranial nerve III controls more functions than pupil dilation, such as eyelid elevation and certain eye movements.

(b) Normal eye movement:

Cranial nerve III paralysis would result in abnormal eye movement due to the loss of control over muscles responsible for moving the eye. Expecting normal eye movement would be incorrect since the paralysis affects the eye's ability to move properly.

Cranial nerve III (oculomotor nerve) paralysis leads to ptosis (drooping eyelid) because it innervates the levator palpebrae superioris muscle. It also affects the pupillary constrictor muscles, resulting in a dilated pupil (lack of pupillary constriction), making this the most comprehensive and accurate answer.

(d) The eye cannot look to the outside side:

Inability to look to the outside (lateral movement) is typically associated with cranial nerve VI (abducens nerve) paralysis, which controls the lateral rectus muscle. Cranial nerve III primarily affects vertical and medial movements, so this is not the expected finding.

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Correct Answer is B

Explanation

A) Color discrimination:

Color discrimination involves assessing the client's ability to differentiate between various colors, typically using color plates like the Ishihara test. This test is often used to detect color blindness or deficiencies in color vision. The action depicted in the image, which involves reading text up close, is not relevant to assessing color vision capabilities.

B) Near vision:

Near vision is assessed by having the client read small text or print held at a close distance, often using a near vision chart or card. The image shows the client covering one eye with an occluder while reading text, which is a common method to test the clarity and focus of near vision. This helps determine if the client has issues such as presbyopia, which affects near vision acuity.

C) Distance vision:

Distance vision is typically evaluated using a Snellen chart, where the client reads letters or symbols from a distance of 20 feet. The test aims to assess the clarity of vision at a distance. The action in the image does not align with this type of assessment, as it focuses on close-up reading rather than distance.

D) Intraocular pressure:

Intraocular pressure is measured using tools like a tonometer to assess the fluid pressure inside the eye, which is crucial for diagnosing conditions like glaucoma. This test involves specific instruments and procedures, unlike the reading task depicted in the image, which is unrelated to measuring eye pressure.

A. Encourage the client to look at the balance beam B. Have the client wear the same clothing every day. C. Weigh the client at the same time in the morning D. Use the same scale to weigh the client. E. Discuss the client's weight with her after each measurement.

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

Explanation

A) Encourage the client to look at the balance beam:

Encouraging the client to look at the balance beam may help her feel more engaged in the process of weight measurement. This can foster trust and cooperation during what may be a challenging procedure due to her history of Anorexia and Bulimia Nervosa.

B) Have the client wear the same clothing every day:

Consistency in clothing helps to minimize variations in weight measurements that could be attributed to changes in clothing weight rather than actual body weight fluctuations. This practice ensures more accurate and reliable serial weight measurements.

C) Weigh the client at the same time in the morning:

Weighing the client at the same time each day helps to standardize conditions and minimize daily variations due to factors like hydration levels and food intake, providing more accurate serial weight measurements.

D) Use the same scale to weigh the client:

Using the same scale ensures consistency in measurement accuracy. Different scales can yield slightly different readings, which could affect the interpretation of weight trends over time.

E) Discuss the client's weight with her after each measurement:

While discussing weight may be part of the client's care plan, it's not necessarily a standard action during the process of conducting serial weight measurements. The focus during the actual weighing process should be on maintaining consistency and accuracy.

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The nurse read the patient's health history cranial nerve III oculomotor paralysis. Which of the following would the nurse expect?

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Correct Answer is B

Explanation

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

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