A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve V?

Listen to the client's speech.

Ask them to read a Snellen chart.

Ask them to identify scented aromas.

Ask them to clench their teeth.

Answer and Explanation

The Correct Answer is D

A.   Listening to speech primarily involves cranial nerves related to speech production (e.g., CN V, CN VII, CN XII) but not specifically for CN V.
B.   Reading a Snellen chart assesses visual acuity, primarily involving cranial nerve II (optic nerve).
C.   Identifying scented aromas involves olfactory nerve (cranial nerve I) assessment.
D.   Asking the client to clench their teeth evaluates the function of the muscles of mastication, which is controlled by cranial nerve V (trigeminal nerve).

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Correct Answer is A

Explanation

A. Vertigo is the sensation of spinning or movement when stationary and is often associated with inner ear problems.
B. Seizure activity involves abnormal electrical activity in the brain and might present with various symptoms but not necessarily the feeling of spinning.
C. Dizziness is a more general term that can include feelings of light-headedness or unsteadiness without a specific spinning sensation.
D. Syncope refers to fainting or loss of consciousness due to decreased blood flow to the brain, not the sensation of spinning.

A. Report the finding, and refer the client to a specialist for further examination. B. Tell the client that a mass was felt, but is nothing to worry about. C. Instruct the client to return for a repeat assessment in 1 month. D. Continue the examination, and document the findings on the chart.

Correct Answer is A

Explanation

A firm, irregularly shaped mass found during a rectal examination could potentially indicate a serious condition such as a tumor or other pathology. It's essential to report such findings and refer the client to a specialist for further evaluation and appropriate diagnosis.
B. It's important not to dismiss or downplay the significance of finding a mass, as it could signify a serious health issue.
C. Waiting a month for reassessment could potentially delay necessary medical intervention if the mass is concerning.
D. While documentation is important, it's crucial to prioritize immediate reporting and referral for further evaluation when such findings are discovered.

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A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve V?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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