Which cranial nerve is assessed by using the Snellen visual acuity chart?

Abducens cranial nerve (CN V).

Optic cranial nerve (CN I).

Trochlear cranial nerve (CN VI).

Oculomotor cranial nerve (CN II).

Answer and Explanation

The Correct Answer is D

Choice A rationale

The abducens cranial nerve (CN VI) controls the lateral rectus muscle of the eye, which is responsible for outward movement. It is not assessed using the Snellen visual acuity chart. The function of this nerve is tested through the evaluation of lateral eye movements.

Choice B rationale

The optic cranial nerve (CN II) is responsible for vision, including visual acuity and visual fields. It is assessed using the Snellen visual acuity chart to determine how well a person can see at various distances. This test evaluates the clarity and sharpness of vision, making CN II the correct answer.

Choice C rationale

The trochlear cranial nerve (CN IV) controls the superior oblique muscle, which helps with downward and inward eye movements. It is not assessed using the Snellen visual acuity chart but rather through the evaluation of eye movements and alignment.

Choice D rationale

The oculomotor cranial nerve (CN III) controls most of the eye's movements, including those of the superior, inferior, and medial rectus muscles, as well as the inferior oblique muscle. It is also responsible for controlling the pupil's response to light. The Snellen visual acuity chart does not assess the function of CN III, as it focuses on visual clarity and acuity.

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Correct Answer is D

Explanation

Choice A rationale

A decreased angle between the cuticles and the nails is not indicative of clubbing. In fact, it is often associated with healthy nails. Clubbing is recognized by changes that increase the angle between the nail bed and the cuticle.

Choice B rationale

An upward curving of the nails, known as koilonychia or spoon nails, is not characteristic of clubbing but is often associated with iron-deficiency anemia. Hence, this answer is incorrect for clubbing.

Choice C rationale

Blue nails indicate cyanosis, which is related to a lack of oxygen in the blood. This is distinct from clubbing, which is more about the shape and angle of the nails rather than their color.

Choice D rationale

Clubbing is recognized by an increase in the angle between the nail bed and the cuticle, often greater than 160 degrees. This is a hallmark feature and the correct indicator of clubbing.

A. Patches of eschar cover parts of the wound. B. Partial thickness skin erosion is observed with a loss of dermis and epidermis. C. Ulcer extends into the subcutaneous tissue. D. Intact skin appears red but not broken. E. Open blister areas have a red-pink wound bed. F. Localized redness in light skin will blanch with fingertip pressure.

Correct Answer is ["B","E"]

Explanation

Choice A rationale

Patches of eschar covering parts of the wound are characteristic of more advanced pressure ulcers, such as Stage III or IV, where necrotic tissue is present. Eschar is a dark, thick, leathery scab or crust that indicates deeper tissue damage and is not observed in Stage II pressure ulcers.

Choice B rationale

A Stage II pressure ulcer is characterized by partial thickness skin erosion with loss of the epidermis and dermis. It appears as a shallow open ulcer with a red-pink wound bed, indicating that the damage has not extended beyond these layers of skin.

Choice C rationale

When a pressure ulcer extends into the subcutaneous tissue, it is classified as a Stage III or IV ulcer, depending on the depth and extent of tissue involvement. Stage II ulcers are limited to the epidermis and dermis and do not reach the subcutaneous layer.

Choice D rationale

Intact skin that appears red but is not broken is indicative of a Stage I pressure ulcer, which represents the earliest stage of pressure injury. Stage I ulcers involve non-blanchable erythema (redness) but no open wound or skin erosion.

Choice E rationale

Open blister areas with a red-pink wound bed are characteristic of Stage II pressure ulcers. These ulcers exhibit partial thickness skin loss and can present as open or fluid-filled blisters with a visible wound bed.

Choice F rationale

Localized redness in light skin that blanches with fingertip pressure is typical of a Stage I pressure ulcer. Blanching erythema indicates that the skin is still viable and blood flow is present, which differentiates Stage I from more advanced stages of pressure injury.

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Which cranial nerve is assessed by using the Snellen visual acuity chart?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing an assessment on the fingers and toes of a patient.What finding is consistent with clubbing?

Correct Answer is D

Explanation

A patient has been admitted to the hospital after the staff at a nursing home noticed a pressure ulcer on his sacral area.The nurse examines the sacral ulcer and determines it is a Stage II ulcer.Which of these findings is characteristic of a Stage II pressure ulcer?

Correct Answer is ["B","E"]

Explanation

During the breast examination of a client, the nurse notes an orange-peel or "peau d'orange" appearance of the skin of the breast.The nurse understands that this appearance of the skin is due to what type of breast condition?

During cardiac examination of a client, the nurse was demonstrating to the student nurse where to locate the Angle of Louis to listen to the Aortic and Pulmonic area on the chest.The nurse should locate the Angle of Louis at the level of what rib?

A nurse expects to hear which percussion sounds over muscles and tissues?

The nurse is reviewing a client's medical record with a documented Snellen exam of 20/50, uncorrected.Patient could read the Rosenbaum chart without difficulty.Based on this information, the client has:

A patient is especially worried about an area of skin on her feet that has turned white.The health care provider has told her that her condition is vitiligo.The nurse explains to her that vitiligo is:

The nurse is examining an elderly client and notes an exaggerated curvature of the thoracic spine.The nurse should document this finding as which of the following?

A student nurse is reviewing for an upcoming examination and recognizes in the ECG readings that the QRS wave represents which of the following?

On assessment of the client's tongue, the client is unable to protrude the tongue and has poor strength on testing against resistance.This would indicate dysfunction of which cranial nerve?