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 D

Explanation

A. Listening to speech primarily assesses cranial nerves related to speech and articulation, not cranial nerve II.
B. Identifying scented aromas assesses the olfactory nerve.
C. Clenching teeth primarily assess cranial nerve V (trigeminal nerve).
D. Cranial nerve II is the optic nerve responsible for vision. Testing visual acuity using a Snellen chart assesses this nerve's function.

A. 1 minute in the center of the abdomen. B. 10 minutes in each quadrant. C. 1 minute in each quadrant. D. 5 minutes in each quadrant. E. None F. None

Correct Answer is D

Explanation

A. One minute may not provide a sufficient duration to declare absent bowel sounds, especially if the client has a slower bowel motility.
B.

Listening for 10 minutes in each quadrant is excessive and not supported by clinical guidelines. It would unnecessarily delay care and increase patient discomfort.

C. One minute in each quadrant might not provide an adequate assessment time.
D. This is the correct answer because clinical guidelines recommend auscultating for at least 5 minutes in each quadrant before concluding that bowel sounds are absent. This ensures sufficient time to detect infrequent bowel sounds and accurately assess the situation.

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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

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

Correct Answer is D

Explanation

During an abdominal assessment, the nurse is unable to hear bowel sounds in a client's abdomen. How long should the nurse listen before reporting absent bowel sounds?

Correct Answer is D

Explanation

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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?

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