A nurse is assessing a client’s cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Eliciting the gag reflex

Checking the pupillary response to light

Observing for facial symmetry

Testing visual acuity

Answer and Explanation

The Correct Answer is B

Choice A reason: Eliciting the gag reflex is not a valid way to assess cranial nerve III. The gag reflex is a protective mechanism that prevents choking or aspiration by triggering a contraction of the pharyngeal muscles when the back of the throat is stimulated. The gag reflex is mediated by cranial nerves IX and X, not III.

Choice B reason: Checking the pupillary response to light is a reliable way to assess cranial nerve III. The pupillary response to light is a reflex that causes the pupil to constrict when exposed to bright light and dilate when exposed to dim light. This reflex helps to regulate the amount of light that enters the eye and protects the retina from damage. The pupillary response to light is controlled by cranial nerve III, which innervates the sphincter pupillae muscle that constricts the pupil.

Choice C reason: Observing for facial symmetry is not a relevant way to assess cranial nerve III. Facial symmetry is the degree of similarity between the two halves of the face. Facial symmetry can be affected by various factors, such as genetics, aging, or facial nerve palsy. Facial nerve palsy is a condition that causes weakness or paralysis of the muscles that control facial expression. Facial nerve palsy is caused by damage to cranial nerve VII, not III.

Choice D reason: Testing visual acuity is not a sufficient way to assess cranial nerve III. Visual acuity is the ability to see fine details and distinguish objects at a distance. Visual acuity depends on various factors, such as the clarity of the lens and cornea, the shape of the eyeball, and the function of the retina. Visual acuity is mainly affected by cranial nerve II, which carries visual information from the retina to the brain. Cranial nerve III does not directly influence visual acuity, but it does innervate some of the muscles that move the eye and enable binocular vision.

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Correct Answer is A

Explanation

Choice A reason: Rinse the mouth after administration. This answer is correct because rinsing the mouth after using inhaled beclomethasone can help prevent oral candidiasis, a fungal infection that can cause soreness, white patches, and bleeding in the mouth.

Choice B reason: Check the pulse after medication administration. This answer is incorrect because checking the pulse after using inhaled beclomethasone is not necessary, as this medication does not affect the heart rate or blood pressure. Inhaled beclomethasone is a corticosteroid that reduces inflammation and swelling in the airways.

Choice C reason: Limit caffeine intake. This answer is incorrect because limiting caffeine intake is not related to the use of inhaled beclomethasone, but rather to the management of asthma symptoms. Caffeine can act as a bronchodilator and improve lung function, but it can also cause nervousness, insomnia, and palpitations in some people.

Choice D reason: Take the medication with meals. This answer is incorrect because taking the medication with meals is not relevant to the use of inhaled beclomethasone, as this medication is not taken orally but by inhalation. Inhaled beclomethasone is delivered directly to the lungs, where it exerts its anti-inflammatory effect.

A. My partner should place their food on the weaker side of their mouth when eating. B. My partner should tilt their head forward when swallowing. C. My partner should cough while swallowing food. D. My partner should sit at a 30° angle while eating their meals.

Correct Answer is B

Explanation

Choice A reason: Placing food on the weaker side of the mouth when eating is not an effective strategy for a client who has dysphagia. This can increase the risk of choking or aspiration, as the food may not be chewed properly or may slip into the airway. The client should place food on the stronger side of the mouth and use the tongue to move it to the back of the throat for swallowing.

Choice B reason: Tilting the head forward when swallowing is an effective technique for a client who has dysphagia. This can help to close off the airway and prevent food or liquid from entering the lungs. The client should also tuck the chin down to the chest and swallow hard.

Choice C reason: Coughing while swallowing food is not a desirable outcome for a client who has dysphagia. This can indicate that the food is going into the wrong pipe and causing irritation or obstruction. The client should try to avoid coughing while swallowing and clear the throat after each bite or sip.

Choice D reason: Sitting at a 30° angle while eating meals is not a sufficient position for a client who has dysphagia. This can still allow food or liquid to flow back into the throat and cause choking or aspiration. The client should sit upright at a 90° angle and remain in that position for at least 30 minutes after eating.

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A nurse is assessing a client’s cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

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