Which technique will the nurse use to assess the patient's olfactory nerve?
Ask the patient to turn his head side-to-side against resistance.
Ask the patient to stick out the tongue and move it side-to-side from midline.
Ask the patient to read the smallest set of letters on a Snellen eye chart.
Ask the patient to identify the smell of vanilla and orange peel.
The Correct Answer is D
Choice A rationale
Asking the patient to turn their head side-to-side against resistance assesses the accessory nerve (cranial nerve XI), which innervates the sternocleidomastoid and trapezius muscles. This action tests muscle strength and integrity of the nerve pathways responsible for head and shoulder movement.
Choice B rationale
Asking the patient to stick out the tongue and move it side-to-side from midline assesses the hypoglossal nerve (cranial nerve XII). This nerve is responsible for the motor control of the intrinsic and extrinsic muscles of the tongue, crucial for speech articulation and swallowing.
Choice C rationale
Asking the patient to read the smallest set of letters on a Snellen eye chart assesses visual acuity, primarily testing the optic nerve (cranial nerve II) and the visual pathways. This evaluates the patient's ability to discern details at a distance.
Choice D rationale
Asking the patient to identify the smell of vanilla and orange peel directly assesses the olfactory nerve (cranial nerve I). This nerve is responsible for the sense of smell, and presenting distinct, non-irritating odors allows for the evaluation of its function and patency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Ankylosis refers to the stiffening and immobility of a joint due to fusion of the bones. This condition is typically caused by chronic inflammation or injury, leading to bone remodeling and eventual bridging of the joint space. It is a pathological process that restricts movement and is not a normal physiological adaptation during pregnancy.
Choice B rationale
Scoliosis is an abnormal lateral curvature of the spine, often accompanied by rotation of the vertebrae. It can be congenital, neuromuscular, or idiopathic. This spinal deformity deviates from the normal sagittal plane alignment and is not a typical physiological compensatory mechanism for the gravid uterus.
Choice C rationale
Kyphosis is an excessive outward curvature of the thoracic spine, resulting in a hunched back appearance. While some degree of thoracic kyphosis is normal, an exaggerated curve can be pathological. It does not represent the compensatory postural change seen in pregnant women, which primarily involves the lumbar region.
Choice D rationale
Lordosis is an increased inward curvature of the lumbar spine. During pregnancy, as the uterus enlarges anteriorly, the woman's center of gravity shifts forward. To maintain balance and prevent falling, the abdominal muscles stretch and the lumbar spine accentuates its inward curve, which is known as lordosis, a physiological adaptation.
Correct Answer is C
Explanation
Choice A rationale
While palpation is a critical skill, this statement does not directly complete the given sentence which defines palpation as a technique. The existing sentence establishes the "what" of palpation, and the completion should elaborate on "how" it's performed or its direct characteristics.
Choice B rationale
Palpation certainly helps identify abnormalities, but this statement describes a benefit or outcome of the technique, not the core method itself as described in the initial sentence. The sentence sets up the physical action, not its diagnostic utility.
Choice C rationale
This choice logically completes the sentence by explaining the *methodology* of palpation, directly following the description of the senses involved and what is being assessed. It specifies that the technique involves "careful and systematic touching of the body," which directly relates to the physical act of assessment.
Choice D rationale
Proper palpation technique ensures accurate examinations, but this statement focuses on the *quality* of the technique rather than describing the technique itself. The initial sentence defines the technique; the completion should expand on its execution, not its outcome. .
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