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?

The sides of the mouth are symmetric when the patient smiles.

The patient's eyes move to the left, right, up, down, and obliquely during conversation.

The patient's eyelids blink periodically.

The patient moistens the lips with the tongue.

Answer and Explanation

The Correct Answer is A

Choice A rationale

The sides of the mouth being symmetric when the patient smiles indicate intact function of the facial cranial nerve (CN VII). This nerve controls the muscles responsible for facial expressions, including smiling, frowning, and closing the eyes. Symmetry in these actions suggests that the facial nerve is functioning properly and that there is no nerve damage or weakness.

Choice B rationale

The patient's eyes moving to the left, right, up, down, and obliquely during conversation are functions of the oculomotor nerve (CN III), trochlear nerve (CN IV), and abducens nerve (CN VI), not the facial cranial nerve (CN VII). These nerves work together to control the movements of the eye muscles, enabling the eyes to move in different directions and maintain proper alignment.

Choice C rationale

Periodic blinking of the eyelids involves the oculomotor nerve (CN III) and the facial nerve (CN VII). The oculomotor nerve controls the muscles that lift the eyelid, while the facial nerve controls the muscles that close the eyelid. Blinking is a coordinated action involving both nerves, but the observation alone is not sufficient to determine the integrity of CN VII.

Choice D rationale

The patient moistening the lips with the tongue involves the function of the hypoglossal nerve (CN XII), which controls the movements of the tongue. The hypoglossal nerve is responsible for the motor control of most of the tongue muscles, allowing for actions like licking the lips, speaking, and swallowing. It is not related to the facial cranial nerve (CN VII).

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Correct Answer is D

Explanation

Choice A rationale

Atrial depolarization refers to the electrical activation of the atria, which is depicted by the P wave on an ECG, not the T wave. The P wave represents the contraction phase of the atria as it pumps blood into the ventricles. Therefore, this option is incorrect for the T wave.

Choice B rationale

Atrial repolarization is the process of the atria returning to their resting state. This repolarization is generally obscured by the QRS complex on an ECG and is not associated with the T wave. Thus, this answer choice is also incorrect.

Choice C rationale

Ventricular depolarization is represented by the QRS complex on an ECG. It indicates the ventricles are contracting to pump blood to the lungs and the rest of the body. Therefore, it does not correlate with the T wave.

Choice D rationale

Ventricular repolarization is indicated by the T wave on an ECG. This phase signifies the ventricles returning to their resting state after the contraction. It is the correct answer as it accurately reflects the T wave's function.

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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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?

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Naxlex Comprehensive Predictor Exams

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

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

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