To assess the tympanic membrane mobility, which instrument is most appropriate for the nurse to use?

Audiometer

Ophthalmoscope

Pneumatic otoscope

Tuning fork

Answer and Explanation

The Correct Answer is C

A. An audiometer is used to assess hearing ability and is not appropriate for examining the tympanic membrane.

B. An ophthalmoscope is used to examine the interior of the eye and cannot assess tympanic membrane mobility.

C. A pneumatic otoscope is specifically designed for examining the tympanic membrane and allows for assessment of its mobility by using air pressure.

D. A tuning fork is used to evaluate hearing and vibration sense, not tympanic membrane mobility.

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Correct Answer is B

Explanation

A. Observing for facial symmetry assesses cranial nerves VII (facial nerve) rather than cranial nerve III.

B. Checking the pupillary response to light assesses cranial nerve III (oculomotor nerve), which controls pupil constriction and extraocular eye movements.

C. Testing visual acuity assesses cranial nerve II (optic nerve), not cranial nerve III.

D. Eliciting the gag reflex assesses cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve III.

A. Planning B. Assessment C. Implementation D. Evaluation

Correct Answer is B

Explanation

A. The planning phase involves setting goals and determining interventions based on the assessment data.

B. The assessment phase is where the nurse gathers information about the client's health history, including potential allergies, which is essential for safe care and diagnostic testing.

C. The implementation phase involves carrying out the planned interventions, which would include considerations for allergies but not the initial questioning about them.

D. The evaluation phase assesses the effectiveness of the interventions and the client's response to care, which is not the appropriate time to inquire about allergies.

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To assess the tympanic membrane mobility, which instrument is most appropriate for the nurse to use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which action should the nurse take to assess cranial nerve III?

Correct Answer is B

Explanation

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Correct Answer is B

Explanation

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