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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Take isoniazid with an antacid. This answer is incorrect because taking isoniazid with an antacid can reduce the absorption and effectiveness of the drug. Isoniazid should be taken on an empty stomach, one hour before or two hours after meals.
Choice B reason: Drink at least 8 ounces of water when you take the pyrazinamide tablet. This answer is incorrect because drinking water with pyrazinamide is not necessary, as this drug does not cause dehydration or kidney problems. However, drinking plenty of fluids is generally recommended for clients with tuberculosis to prevent dehydration and help clear the lungs of secretions.
Choice C reason: Expect your sputum cultures to be negative after 6 months of therapy. This answer is incorrect because expecting sputum cultures to be negative after 6 months of therapy is unrealistic and misleading. The duration of treatment for tuberculosis varies depending on the type and extent of the infection, the drug regimen, and the client's response to the therapy. Some clients may need longer than 6 months to achieve negative sputum cultures.
Choice D reason: Provide a sputum specimen every 2 weeks to the clinic for testing. This answer is correct because providing sputum specimens regularly is important to monitor the effectiveness of the treatment and to determine when the client is no longer infectious.
Correct Answer is C
Explanation
Choice A reason: Decrease respiratory secretions. This answer is incorrect because pancuronium does not have any effect on the production or clearance of respiratory secretions. This medication is not used to treat the pulmonary edema and inflammation that occur in ARDS.
Choice B reason: Induce sedation. This answer is incorrect because pancuronium does not have any sedative or analgesic properties. This medication does not affect the level of consciousness or pain perception of the client. A client who receives pancuronium should also receive adequate sedation and analgesia to prevent anxiety and discomfort.
Choice C reason: Suppress respiratory effort. This answer is correct because pancuronium is a neuromuscular blocker that inhibits the transmission of nerve impulses to the muscles, causing paralysis and relaxation. This medication is used to suppress the respiratory effort of the client and allow the mechanical ventilator to control the breathing.
Choice D reason: Decrease chest wall compliance. This answer is incorrect because pancuronium does not have any effect on the elasticity or stiffness of the chest wall. This medication is not used to treat the reduced lung compliance and increased airway resistance that occur in ARDS.
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