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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Estimating the degree of flexion and extension in each joint is more related to joint range of motion, not muscle strength.
Choice B rationale: Measuring the degree of force that it takes to overcome joint flexion or extension is not a standard method for assessing muscle strength.
Choice C rationale: To assess muscle strength, the nurse should apply an opposing force when the individual puts a joint in flexion or extension. This helps evaluate the strength of the muscles and their ability to move the joint against resistance.
Choice D rationale: Observing muscles for the degree of contraction when lifting a heavy object may provide information on muscle function but is not a specific muscle strength assessment.
Correct Answer is D
Explanation
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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