A. Facial, Trigeminal, Vestibulocochlear: The Facial nerve (VII) is primarily responsible for facial expressions and taste sensation. The Trigeminal nerve (V) is involved in facial sensation and chewing. The Vestibulocochlear nerve (VIII) deals with hearing and balance, not eye movements.

B. Oculomotor, Trochlear, and Abducens: The Oculomotor nerve (III) controls most of the eye's movements, including constriction of the pupil. The Trochlear nerve (IV) innervates the superior oblique muscle, enabling downward and outward eye movements. The Abducens nerve (VI) controls the lateral rectus muscle, responsible for lateral eye movement.

C. Spinal Accessory, Facial, Trigeminal: The Spinal Accessory nerve (XI) controls neck and shoulder movements, not eye movements. The Facial nerve (VII) and Trigeminal nerve (V) are also not involved in eye movements.

D. Glossopharyngeal, Vagus, Hypoglossal: The Glossopharyngeal nerve (IX) is involved in taste and salivation. The Vagus nerve (X) controls parasympathetic functions and throat muscles. The Hypoglossal nerve (XII) controls tongue movements. None of these nerves are responsible for eye movements.

A. Blood pressure pattern: Blood pressure patterns are crucial for assessing cardiovascular health as they indicate potential issues like hypertension or hypotension, which are related to heart function.

B. Dyspnea: Dyspnea (difficulty breathing) is important in a cardiovascular assessment as it can be a sign of heart failure or other cardiac conditions affecting respiratory function.

C. Vision Acuity: While vision acuity is important for overall health, it is not directly related to cardiovascular assessment and does not provide information about heart or vascular health.

D. Peripheral Edema: Peripheral edema (swelling in the limbs) can be a sign of heart failure or other circulatory problems, making it relevant for cardiovascular assessment.

E. Constipation: Although constipation can affect overall health, it is not typically included in a cardiovascular assessment as it does not provide direct information about cardiovascular status.

A. Ears: Evaluation of the ears is primarily concerned with hearing and balance, which involve cranial nerves such as VIII (Vestibulocochlear), not IX, X, and XII.

B. Mouth and throat: Cranial nerves IX (Glossopharyngeal), X (Vagus), and XII (Hypoglossal) are assessed through the examination of the mouth and throat. CN IX and X are evaluated by checking the gag reflex and the ability to swallow, while CN XII is assessed by examining tongue movements.

C. Head and face: The assessment of the head and face generally involves cranial nerves V (Trigeminal) and VII (Facial), which control facial sensation and movement, rather than IX, X, and XII.

D. Mental status examination: While mental status is crucial for overall health assessment, it does not specifically target cranial nerves IX, X, and XII.

A. Apparent state of health: This generally reflects overall health rather than specific mental or cognitive status.

B. Facial expression: Facial expression provides insight into mood and emotional state but does not specifically assess consciousness or orientation.

C. Level of consciousness: Being awake, alert, and oriented is directly related to the level of consciousness, which is a key aspect of assessing cognitive and mental function.

D. Posture, gait, motor activity, and speech: These aspects are relevant for physical activity and motor skills, not specifically for consciousness or cognitive orientation.

Rationale:
A. Blood pressure pattern: Monitoring blood pressure patterns is essential for evaluating cardiovascular health as it provides information on hypertension or hypotension, which are significant for heart function.

B. Dyspnea: Dyspnea (difficulty breathing) can indicate cardiovascular issues such as heart failure, making it a relevant aspect of cardiovascular assessment.

C. Vision Acuity: While vision acuity is important for overall health, it is not directly related to cardiovascular assessment and does not provide specific information about heart or vascular health.

D. Peripheral Edema: Peripheral edema (swelling in the extremities) can be a sign of cardiovascular problems like heart failure or venous insufficiency, thus important for cardiovascular assessment.

E. Constipation: Although constipation affects general health, it does not directly relate to cardiovascular assessment and is not typically included in this context.

A. Use tangential lighting: Tangential lighting is not typically used for assessing heart impulses; it is more useful for examining surface characteristics of the skin.

B. Assist the client to a standing position: The client should be in a supine or semi-recumbent position for accurate inspection of apical heart impulses, not standing.

C. Use perpendicular lighting: Perpendicular lighting is crucial for accurately visualizing apical heart impulses, as it helps to clearly observe the movement of the heart against the chest wall.

D. Focus a penlight on the client's chest: While a penlight can be used in physical assessments, perpendicular lighting is more effective for clearly seeing the apical heart impulses.

A. VII: The Facial nerve (VII) is responsible for taste sensation in the anterior two-thirds of the tongue. An inability to taste in this area indicates a dysfunction in this nerve.

B. XII: The Hypoglossal nerve (XII) controls tongue movements but does not involve taste sensation.

C. V: The Trigeminal nerve (V) provides sensation to the face and mouth but is not responsible for taste.

D. II: The Optic nerve (II) is involved in vision, not taste.

A. Facial, Trigeminal, Vestibulocochlear: The Facial nerve (VII) controls facial expressions, the Trigeminal nerve (V) is involved in facial sensation, and the Vestibulocochlear nerve (VIII) handles hearing and balance, none of which are directly related to eye movements.

B. Oculomotor, Trochlear, and Abducens: The Oculomotor nerve (III) controls most eye movements, the Trochlear nerve (IV) controls the superior oblique muscle for downward and outward movements, and the Abducens nerve (VI) controls the lateral rectus muscle for lateral eye movement.

C. Spinal Accessory, Facial, Trigeminal: The Spinal Accessory nerve (XI) controls neck and shoulder movements, while the Facial nerve (VII) and Trigeminal nerve (V) are not involved in eye movements.

D. Glossopharyngeal, Vagus, Hypoglossal: The Glossopharyngeal nerve (IX) is involved in taste and salivation, the Vagus nerve (X) affects parasympathetic functions, and the Hypoglossal nerve (XII) controls tongue movements, none of which are related to eye movements.

A. Planning: Planning involves setting goals and interventions based on data collected, but data collection itself is not part of this phase.

B. Diagnosis: Diagnosis involves analyzing collected data to identify health issues, but data collection is a separate process that occurs before this phase.

C. Evaluation: Evaluation assesses the effectiveness of interventions and progress towards goals, but data collection is performed earlier in the process.

D. Assessment: Data collection is a fundamental part of the assessment phase in the nursing process, where information is gathered to identify patient needs and conditions.

A. External Eye Structures: This assessment involves examining the visible parts of the eye and surrounding structures, not the distance vision.

B. Near Vision: Near vision is typically assessed using a reading chart held at a close distance, not a chart mounted on the wall.

C. Peripheral Vision: Peripheral vision assessments involve testing the field of vision to detect loss or abnormalities, rather than focusing on distant vision.

D. Distant Vision: Standing 20 feet from a chart to read letters tests distant vision, as it assesses the ability to see objects clearly at a distance.