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: Asymmetry with one side hanging lower than the other is a normal variation in scrotal anatomy.

Choice B rationale: Marked tenderness on palpation of the scrotum is abnormal and may indicate inflammation or infection.

Choice C rationale: Easy sliding of scrotal contents when palpated is a normal finding.

Choice D rationale: Small, firm, nontender, yellowish nodules may represent sebaceous cysts or Fordyce spots, which are typically benign and not a cause for concern.

A. Tell the adolescent, everything will be fine and there’s nothing to worry about. B. Complete an assessment and notify the emergency department physician immediately. C. Perform a focused assessment and document. D. Document pain assessment as normal

Correct Answer is B

Explanation

A. Reassuring the adolescent without assessment minimizes a potentially serious condition. Sudden, severe testicular pain can indicate testicular torsion, which is a medical emergency.

B. Completing a rapid assessment and notifying the emergency department physician immediately is the priority. Testicular torsion requires urgent evaluation and intervention to preserve blood flow and prevent permanent damage.

C. Performing a focused assessment is appropriate, but documentation alone delays necessary medical intervention. Notification of the provider must occur promptly.

D. Documenting the pain assessment as normal is inaccurate and unsafe, given the adolescent’s report of excruciating pain.

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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?

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Naxlex Comprehensive Predictor Exams

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