What neurologic assessment should the nurse perform to gauge the client's function of cranial nerve 1?
Have the client identify familiar odors with the eyes closed
Assess papillary reflex
Test for air and bone conduction (Rinne test)
Utilize the Snellen chart
The Correct Answer is A
A. Have the client identify familiar odors with the eyes closed: Cranial nerve I (olfactory nerve) controls the sense of smell. The correct way to assess its function is by asking the client to identify familiar, non-irritating odors like coffee or peppermint with their eyes closed to eliminate visual clues.
B. Assess pupillary reflex: Pupillary reflex testing evaluates cranial nerves II (optic) and III (oculomotor), which are responsible for visual input and eye muscle response, not olfaction.
C. Test for air and bone conduction (Rinne test): The Rinne test assesses cranial nerve VIII (vestibulocochlear), which is responsible for hearing and balance. It has no relation to the sense of smell.
D. Utilize the Snellen chart: The Snellen chart evaluates visual acuity, which tests cranial nerve II (optic nerve). This assessment is used for vision, not olfactory function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Arrange for a STAT assessment of the client's serum calcium levels: Serum calcium levels are not directly related to compartment syndrome. The condition results from increased pressure within a muscle compartment, not disturbances in calcium metabolism, so this action would not be appropriate or time-sensitive.
B. Perform active range of motion exercises: Encouraging movement in a limb with potential compartment syndrome could worsen pain and damage. The affected area should be immobilized and elevated until the provider evaluates the condition, not exercised.
C. Assess the client's joint function symmetrically: While comparing limbs is helpful in early assessment, once signs of compartment syndrome are present, delaying action for further assessment is inappropriate. Prompt intervention is critical to prevent permanent nerve and muscle damage.
D. Contact the primary provider immediately: Compartment syndrome is a surgical emergency. Immediate notification of the provider is required so that pressure-relieving interventions such as a fasciotomy or cast removal can be performed without delay.
Correct Answer is A
Explanation
A. Place a wedge pillow between the legs: A wedge pillow maintains proper hip abduction and prevents the legs from crossing the midline, reducing the risk of hip dislocation after surgery. It stabilizes the joint and ensures that the hip remains in a neutral position during recovery.
B. Elevate the head of the bed to a Fowler's position: Elevating the head of the bed too far can cause hip flexion greater than 90 degrees, increasing the risk of dislocation. While slight elevation may aid comfort and breathing, high Fowler’s should be avoided post-hip arthroplasty.
C. Position the legs in alignment with the spine: While keeping the legs straight may seem neutral, this position does not prevent the legs from adducting or rotating inward, which can contribute to dislocation risk. Abduction is more protective in this context.
D. Place a footboard on the bed: A footboard can help prevent foot drop but does not play a role in preventing hip dislocation. It provides no stabilization to the hip joint and does not ensure safe alignment of the lower extremities.
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