A nurse is assessing a client’s cranial nerves. Which methods should the nurse use to assess cranial nerve V?
A nurse is educating a client about supplements that are effective for nausea. Which supplement should the nurse include?
Ask the client to clench their teeth.
Ask the client to read a Snellen chart.
Ask the client to raise his eyebrows.
The Correct Answer is B
Choice A Reason:
Listening to the client’s speech is not a method used to assess cranial nerve V. This method is more relevant for assessing cranial nerves IX (Glossopharyngeal) and X (Vagus), which are involved in speech and swallowing.
Choice B Reason:
Clenching the teeth is a method used to assess the motor function of cranial nerve V (the trigeminal nerve). The trigeminal nerve is responsible for the movement of the muscles involved in chewing. When a client clenches their teeth, the nurse can palpate the masseter and temporal muscles to check for strength and symmetry. This helps determine if there are any abnormalities in the motor function of the trigeminal nerve.
Choice C Reason:
Asking the client to read a Snellen chart is a method used to assess cranial nerve II (Optic), which is responsible for vision. This method does not assess cranial nerve V.
Choice D Reason:
Asking the client to raise his eyebrows is a method used to assess cranial nerve VII (Facial), which controls facial expressions. This method is not used to assess cranial nerve V.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.4"]
Explanation
Step-by-Step Calculation
Step 1: Identify the desired dose and the concentration of the medication.
Desired dose = 4 mg
Concentration = 10 mg/mL
Step 2: Set up the calculation to find the volume to administer.
Volume to administer (mL) = Desired dose (mg) ÷ Concentration (mg/mL)
Step 3: Perform the division.
4 mg ÷ 10 mg/mL = 0.4 mL
Step 4: Round the answer to the nearest whole number.
0.4 mL rounded to the nearest whole number is 0 mL
Step 5: Apply the instruction to use a leading zero if it applies and do not use a trailing zero.
The final volume to administer is 0.4 mL.
Therefore, the nurse should administer 0.4 mL of furosemide via IV bolus to the client.
Correct Answer is A
Explanation
Choice A Reason:
Restlessness is often one of the earliest signs of hypoxia. When the body experiences low oxygen levels, the brain is one of the first organs to be affected. This can lead to symptoms such as anxiety, agitation, and restlessness as the brain struggles to function properly without adequate oxygen. These symptoms occur because the body is trying to compensate for the lack of oxygen by increasing respiratory and heart rates, which can make a person feel uneasy or restless.
Choice B Reason:
Cyanosis refers to a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. While cyanosis is a significant indicator of hypoxia, it is typically a later sign. By the time cyanosis is visible, hypoxia has usually been present for some time, and oxygen levels have been critically low. Therefore, it is not the earliest clinical manifestation of hypoxia.
Choice C Reason:
Apnea is the absence of breathing. This is a severe and late sign of hypoxia. When a person stops breathing, it indicates that the body has been deprived of oxygen for an extended period, leading to critical conditions. Apnea is a medical emergency and requires immediate intervention, but it is not an early sign of hypoxia.
Choice D Reason:
Bradycardia is a slower than normal heart rate. Like apnea, bradycardia is a late sign of hypoxia. Initially, the body responds to low oxygen levels by increasing the heart rate (tachycardia) to pump more oxygenated blood to tissues. Bradycardia occurs when the body can no longer compensate, and the heart rate slows down, indicating severe hypoxia and impending failure of the cardiovascular system.
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