When inspecting a patient's eyes, the nurse assesses the presence of cranial nerve III (oculomotor nerve) by observing the eyelids open and close bilaterally.
What other technique does a nurse use to test the function of this cranial nerve?
Visual acuity.
Peripheral vision.
Presence of the red reflex.
Pupillary constriction to light.
The Correct Answer is D
Choice A rationale
Visual acuity tests assess the clarity of vision and the ability to discern letters or numbers at a set distance. It is used to test the function of cranial nerve II (optic nerve) rather than cranial nerve III (oculomotor nerve). Testing visual acuity involves using eye charts and assessing each eye separately.
Choice B rationale
Peripheral vision tests evaluate the ability to see objects outside the direct line of vision and are used to test the function of cranial nerve II (optic nerve). Peripheral vision assessment helps in diagnosing conditions like glaucoma but does not test the function of cranial nerve III.
Choice C rationale
The presence of the red reflex is assessed by looking into the eye with an ophthalmoscope to check for abnormalities in the eye's posterior segment. It is not related to the function of cranial nerve III but rather indicates healthy eye structures, including the retina and optic nerve (cranial nerve II).
Choice D rationale
Pupillary constriction to light is a direct test of cranial nerve III function. The oculomotor nerve controls the constriction of the pupil in response to light. By shining a light into the eyes and observing the pupils' response, the nurse can assess the integrity of cranial nerve III.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Functional incontinence occurs when an individual cannot reach the bathroom in time due to physical or cognitive limitations. It is not related to stress or pressure on the bladder but rather to external factors that impede timely access to toileting facilities.
Choice B rationale
Reflex incontinence is characterized by involuntary loss of urine due to a lack of signal awareness or detrusor muscle overactivity. It is typically associated with neurological conditions such as spinal cord injuries or multiple sclerosis. This type of incontinence does not involve stress-related triggers like coughing or sneezing.
Choice C rationale
Stress incontinence involves the involuntary leakage of urine during activities that increase intra-abdominal pressure, such as coughing, sneezing, laughing, or physical exertion. This type of incontinence is commonly seen in women, particularly after childbirth or during menopause, due to weakened pelvic floor muscles or sphincter dysfunction.
Choice D rationale
Urge incontinence is characterized by a sudden and intense urge to urinate, often resulting in involuntary urine leakage before reaching the bathroom. It is typically caused by overactive bladder muscles or nerve signals and is not specifically triggered by actions like coughing or sneezing.
Correct Answer is C
Explanation
Choice A rationale
The optic nerve (CN II) is responsible for vision, transmitting visual information from the retina to the brain. Dysfunction of the optic nerve would result in visual disturbances, such as loss of vision or changes in visual acuity, rather than difficulty with tongue movement. This nerve does not control motor functions of the tongue.
Choice B rationale
The abducens nerve (CN VI) controls the lateral rectus muscle of the eye, which is responsible for moving the eye outward, away from the nose. Dysfunction of the abducens nerve would result in issues with eye movement, such as double vision or inability to move the eye laterally, not tongue movement. It does not play a role in tongue motor control.
Choice C rationale
The hypoglossal nerve (CN XII) controls the muscles of the tongue, enabling movements necessary for speech, swallowing, and mastication. Dysfunction of this nerve would result in difficulty protruding the tongue and reduced strength during resistance testing. Symptoms can include atrophy of the tongue muscles, fasciculations, and deviation of the tongue to one side when extended.
Choice D rationale
The vestibulocochlear nerve (CN VIII) is responsible for hearing and balance, transmitting sound and equilibrium information from the inner ear to the brain. Dysfunction of the vestibulocochlear nerve would lead to symptoms such as hearing loss, tinnitus, or balance disorders like vertigo. It does not affect the motor control of the tongue.
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