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 D
Explanation
Choice A Reason:
“Call the provider” is important but not the first priority. The immediate concern is to maintain the client’s intravenous access to ensure they can receive any necessary medications or fluids promptly. Once the line is secured, the provider should be notified to receive further instructions and manage the client’s condition.
Choice B Reason:
“Notify the blood bank” is also crucial but comes after ensuring the client’s immediate safety. The blood bank needs to be informed to investigate the cause of the reaction and prevent further issues, but this step follows the initial emergency interventions.
Choice C Reason:
“Collect a urine specimen” is necessary to check for hemolysis, which can occur during a transfusion reaction. However, this is not the first step. The priority is to stabilize the client by maintaining IV access with normal saline.
Choice D Reason:
“Keep the line open with 0.9% NS through new tubing” is the correct first intervention. This action ensures that the client remains hydrated and that the IV line is available for any emergency medications or treatments. Using new tubing prevents any contamination from the transfusion set.
Correct Answer is A
Explanation
Choice A Reason:
Metabolic Alkalosis is correct. The pH of 7.56 is above the normal range (7.35-7.45), indicating alkalosis. The HCO3 level of 33 mEq/L is also above the normal range (22-28 mEq/L), which suggests a metabolic cause. In metabolic alkalosis, the body has an excess of bicarbonate or a loss of hydrogen ions.
Choice B Reason:
Metabolic Acidosis is incorrect. Metabolic acidosis is characterized by a low pH (below 7.35) and a low HCO3 level (below 22 mEq/L). The given values indicate alkalosis, not acidosis.
Choice C Reason:
Respiratory Alkalosis is incorrect. Respiratory alkalosis is characterized by a high pH (above 7.45) and a low PaCO2 (below 35 mmHg). In this case, the PaCO2 is elevated (55 mmHg), which does not align with respiratory alkalosis.
Choice D Reason:
Respiratory Acidosis is incorrect. Respiratory acidosis is characterized by a low pH (below 7.35) and a high PaCO2 (above 45 mmHg). While the PaCO2 is elevated, the pH indicates alkalosis, not acidosis.
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