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

Listen to the client’s speech

Ask the client to identify scented aromas

Ask the client to clench his teeth

Ask the client to read a Snellen chart

Answer and Explanation

The Correct Answer is D

Choice A rationale: Listening to the client's speech is not related to the assessment of cranial nerve II.

Choice B rationale: Assessing the ability to identify scented aromas is more related to cranial nerve I (olfactory nerve).

Choice C rationale: Asking the client to clench their teeth is related to the assessment of cranial nerve V (trigeminal nerve).

Choice D rationale: Cranial nerve II, the optic nerve, is responsible for vision. The nurse should use the Snellen chart to assess visual acuity.

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Correct Answer is B

Explanation

Choice A rationale: A normal capillary refill time is less than 3 seconds, which indicates adequate blood flow and oxygenation.

Choice B rationale: Radial pulses 2+ with regular rate and rhythm bilaterally are expected findings in a peripheral vascular assessment, indicating normal blood flow to the extremities.

Choice C rationale: Pale and cool feet may indicate decreased blood flow and are not expected findings.

Choice D rationale: Ankle edema may indicate venous insufficiency or other circulatory issues, and it is not an expected finding in a healthy peripheral vascular assessment.

A. "With aging, a large amount of subcutaneous fat is lost, which gives the appearance of decreased height." B. "With aging, the spine is not as flexible, which doesn't permit the individual to stand as tall." C. "With aging, the cartilage between the bones in the spine gets worn down, which causes decreased height." D. "With aging, thickening of the intervertebral disks occurs, which causes pressure breakdown of the spinal vertebrae."

Correct Answer is C

Explanation

Choice A rationale: Loss of subcutaneous fat is not a primary factor contributing to decreased height with aging.

Choice B rationale: The flexibility of the spine may contribute to posture but is not the primary reason for a significant decrease in height.

Choice C rationale: With aging, the cartilage between the bones in the spine gets worn down, leading to decreased height. This is due to degenerative changes in the intervertebral disks.

Choice D rationale: Thickening of intervertebral disks is not typically associated with aging and decreased height. Degeneration and thinning of the disks are more common factors.

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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 II?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has completed a peripheral vascular assessment on a client. Which of the following would the nurse document as expected findings?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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