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 ["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.

A. Rhonchi. B. Stridor. C. Wheezes. D. Crackles.

Correct Answer is C

Explanation

Choice A rationale

Rhonchi are low-pitched, coarse sounds typically heard during expiration, associated with secretions in large airways, not high-pitched continuous sounds.

Choice B rationale

Stridor is a high-pitched sound heard during inspiration, typically indicating upper airway obstruction.

Choice C rationale

Wheezes are continuous high-pitched whistling sounds heard during expiration, common in conditions like chronic obstructive pulmonary disease, where airway narrowing is present.

Choice D rationale

Crackles are discontinuous sounds heard during inspiration, usually associated with fluid in the lungs or alveolar opening, not continuous high-pitched sounds. .

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

A nurse is auscultating the breath sounds of a client who has chronic obstructive pulmonary disease.When the client exhales, the nurse hears continuous high-pitched whistling sound.The nurse should document this as?

Correct Answer is C

Explanation

While taking a history, the nurse observes that the patient's facial cranial nerves (CN VII) are intact based on which behaviors of the patient?

A client reports dizziness on her yearly physical exam.Which of the following tests would be the most appropriate to assess the client's equilibrium?

A nurse is providing education for a client who has glaucoma.Which of the following statements should the nurse include in the teaching?

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The instructor asks the student nurse to auscultate the client's Erb's Point. Where is the cardiac landmark referred to as the Erb's Point located?

A nurse is assessing a client at a dermatology clinic.Which of the following findings places the client at risk for developing malignant melanoma?

The nurse is assessing the chest shape of a patient.Which chest configuration describes a sunken in sternum and costal cartilage?

The nurse is assessing a skin lesion using the ABCDE criteria.The nurse understands "C" stands for: