The nurse walks in and finds the patient who is not able to sleep because they are having a mastectomy surgery in the morning. Which therapeutic response is most appropriate?

Choice A reason: Cranial nerve I (olfactory) assesses smell, not facial movements. Smiling or frowning involves facial muscles, unrelated to olfactory function. Testing nerve I involves odor identification, not motor actions, making it irrelevant to this assessment, per cranial nerve examination protocols.

Choice B reason: Cranial nerves II (optic) and III (oculomotor) control vision and eye movement, not facial expressions. Actions like smiling or puffing cheeks involve facial muscles, not pupil response or gaze, which are tested for II and III, per neurological assessment standards.

Choice C reason: Cranial nerve VII (facial) controls facial expressions, including smiling, frowning, wrinkling the forehead, and puffing cheeks. Testing these actions assesses motor function, confirming nerve integrity. This is a key part of neurological exams, detecting deficits like Bell’s palsy, per cranial nerve assessment guidelines.

Choice D reason: Cranial nerve VII (vestibulocochlear VIII (auditory) assesses hearing and balance, not facial movements. Actions like smiling or puffing cheeks are unrelated to auditory or vestibular function, making this nerve irrelevant to the described assessment, per neurological examination protocols.

Choice A reason: The Quality and Safety Education for Nurses (QSEN) focuses on competencies like patient safety and quality improvement, not moral standards. It guides nursing education to enhance clinical skills and patient outcomes, addressing evidence-based practice and teamwork. Moral standards, involving ethical decision-making and professional conduct, are governed by the ANA Code of Ethics, not QSEN.

Choice B reason: The American Nurses Association Standards of Professional Performance outline behaviors like leadership and collaboration but focus on professional competence, not moral standards. These standards guide performance expectations, such as resource utilization and communication, rather than ethical principles like beneficence or autonomy, which are central to the ANA Code of Ethics for moral guidance.

Choice C reason: The American Nurses Association Code of Ethics provides moral standards for nursing, emphasizing principles like beneficence, nonmaleficence, autonomy, and justice. It guides ethical decision-making in patient care, addressing dilemmas like informed consent and confidentiality. This code ensures nurses uphold moral integrity in professional behavior, making it the correct guide for ethical standards.

Choice D reason: The American Nurses Association Standards of Practice define the nursing process (assessment, diagnosis, planning, etc.) but focus on clinical practice standards, not moral guidelines. These standards ensure competent care delivery but do not address ethical principles like patient autonomy or ethical dilemmas, which are covered by the ANA Code of Ethics.