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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?

A.

Listen to the client’s speech

B.

Ask the client to identify scented aromas

C.

Ask the client to clench his teeth

D.

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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Related Questions

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.

Correct Answer is B

Explanation

Choice A rationale: Telling the adolescent that everything will be fine without a thorough assessment may delay necessary interventions.
Choice B rationale: Excruciating pain in the testicle requires immediate attention since it could be an indication of testicular torsion. The nurse should complete an assessment and notify the emergency department physician promptly.
Choice C rationale: While documentation is important, the priority is to address the immediate needs of the adolescent in severe pain.
Choice D rationale: Documenting pain assessment as normal is not appropriate when the client is experiencing excruciating pain.

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