The patient reports an inability to taste. What is the most appropriate action for the nurse to take?
Test the hypoglossal nerve.
Evaluate the function of the Cranial nerve XI (11)
Test the glossopharyngeal nerve.
Evaluate sensory function.
The Correct Answer is D
The sense of taste is primarily mediated by the facial nerve (cranial nerve VII) and the glossopharyngeal nerve (cranial nerve IX). However, testing the function of specific cranial nerves such as the hypoglossal nerve (cranial nerve XII) or cranial nerve XI (11) is not directly related to evaluating the patient's ability to taste. Therefore, options a, b, and c would not be the most appropriate actions for the nurse to take in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Objective data are measurable and observable findings that can be obtained through physical examination, laboratory tests, or other diagnostic procedures.
Option A is subjective data because it is information reported by the patient and may not be entirely accurate. Option Bis also subjective data because it is the patient's perception of their weight loss, which may not be an accurate reflection of actual weight loss.
Option Dis also subjective data because it relies on the patient's self-report of their alcohol intake, which may not be entirely accurate.
Correct Answer is A
Explanation
A. The examiner uses bimanual palpitation to evaluate the tail of spence.
This statement is true. The tail of Spence is the extension of breast tissue into the axilla, and it is important to evaluate this area during a breast examination. Bimanual palpation, which involves using both hands to examine the breast tissue, is commonly used to assess the tail of Spence.
B. The axillae are not palpated if the breast tissue is normal.
This statement is false. The axillae should be palpated during a breast examination, even if the breast tissue is normal. Lymph nodes in the axilla can sometimes be the first site of metastasis for breast cancer, so it is important to check for any abnormalities in this area.
C. Nipple discharge in pregnant women is considered abnormal.
This statement is false. Nipple discharge is a common occurrence during pregnancy and is usually considered normal, especially in the later stages of pregnancy. However, any sudden or persistent discharge should be evaluated by a healthcare provider.
D. The breasts are inspected as the client changes positions to detect abnormal symmetry.
This statement is false. The breasts should be inspected in a consistent position, such as with the patient sitting or lying down. Changing positions can alter the appearance of the breasts and make it difficult to detect any changes or abnormalities. However, it is important to inspect both breasts and compare them for any signs of asymmetry or abnormalities.
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