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 A

Explanation

Choice A rationale: Taking an iron supplement can lead to nontarry and black stool due to the dark color of iron.

Choice B rationale: Dry heaves are not typically associated with nontarry black stool. Choice C rationale: Eating red meat would result in reddish stool, not black. Choice D rationale: Loss of appetite is not directly related to the appearance of stool.

A. ability to swallow pureed foods B. client reports mild headache C. Weakness D. Glasgow comma scale of 5

Correct Answer is D

Explanation

Choice A rationale: The ability to swallow pureed foods is not an immediate concern and does not indicate a life-threatening condition.

Choice B rationale: Mild headache, while noteworthy, may not require immediate attention unless it is accompanied by other concerning symptoms.

Choice C rationale: Weakness is a general symptom that should be further assessed for severity and associated symptoms before determining the urgency of intervention. The GCS score of 5 takes precedence in this context.

Choice D rationale: A Glasgow Coma Scale (GCS) of 5 indicates severe impairment of consciousness and requires immediate attention. A lower GCS score reflects a deeper level of coma.

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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

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