A nurse is assessing cranial nerve VIII.
What tests will be administered on the client?

Whisper and Romberg tests.

PERRLA and EOMs.

Snellen and Rosenbaum tests.

Rinne and Weber tests.

Answer and Explanation

The Correct Answer is D

Choice A rationale

The Whisper test evaluates hearing acuity, while the Romberg test assesses balance and proprioception by having the client stand with feet together and eyes closed. Both tests involve sensory assessments but do not directly assess cranial nerve VIII, which is the vestibulocochlear nerve responsible for hearing and balance.

Choice B rationale

PERRLA (pupils equal, round, reactive to light and accommodation) assesses cranial nerves II and III, while EOMs (extraocular movements) assess cranial nerves III, IV, and VI. These tests do not evaluate cranial nerve VIII.

Choice C rationale

Snellen and Rosenbaum tests measure visual acuity for distance and near vision, respectively. These tests assess cranial nerves II and III but do not evaluate cranial nerve VIII.

Choice D rationale

The Rinne and Weber tests are audiometric assessments that specifically evaluate cranial nerve VIII, which controls hearing and balance. The Rinne test compares air and bone conduction of sound, while the Weber test assesses sound lateralization, making them appropriate tests for assessing cranial nerve VIII.

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Correct Answer is C

Explanation

Choice A rationale

Patients with hyperopia (farsightedness) are able to see distant objects clearly but may have difficulty focusing on near objects. They can pass the Snellen exam, which measures distance vision, but may struggle with close-up tasks.

Choice B rationale

Hyperopia involves difficulty seeing close objects, not distant ones. Therefore, patients with hyperopia would not have difficulty seeing from far or at a distance, making this statement incorrect.

Choice C rationale

Hyperopia, or farsightedness, is characterized by the inability to see objects or letters that are close in range. It occurs when the eye's shape causes light to focus behind the retina instead of directly on it, leading to blurred near vision. Corrective lenses can help focus light properly on the retina.

Choice D rationale

The Rosenbaum chart is used to assess near vision acuity, which would highlight issues with hyperopia. However, patients with hyperopia would pass the Snellen exam, which tests distance vision, but might struggle with the Rosenbaum chart. .

A. Patches of eschar cover parts of the wound. B. Partial thickness skin erosion is observed with a loss of dermis and epidermis. C. Ulcer extends into the subcutaneous tissue. D. Intact skin appears red but not broken. E. Open blister areas have a red-pink wound bed. F. Localized redness in light skin will blanch with fingertip pressure.

Correct Answer is ["B","E"]

Explanation

Choice A rationale

Patches of eschar covering parts of the wound are characteristic of more advanced pressure ulcers, such as Stage III or IV, where necrotic tissue is present. Eschar is a dark, thick, leathery scab or crust that indicates deeper tissue damage and is not observed in Stage II pressure ulcers.

Choice B rationale

A Stage II pressure ulcer is characterized by partial thickness skin erosion with loss of the epidermis and dermis. It appears as a shallow open ulcer with a red-pink wound bed, indicating that the damage has not extended beyond these layers of skin.

Choice C rationale

When a pressure ulcer extends into the subcutaneous tissue, it is classified as a Stage III or IV ulcer, depending on the depth and extent of tissue involvement. Stage II ulcers are limited to the epidermis and dermis and do not reach the subcutaneous layer.

Choice D rationale

Intact skin that appears red but is not broken is indicative of a Stage I pressure ulcer, which represents the earliest stage of pressure injury. Stage I ulcers involve non-blanchable erythema (redness) but no open wound or skin erosion.

Choice E rationale

Open blister areas with a red-pink wound bed are characteristic of Stage II pressure ulcers. These ulcers exhibit partial thickness skin loss and can present as open or fluid-filled blisters with a visible wound bed.

Choice F rationale

Localized redness in light skin that blanches with fingertip pressure is typical of a Stage I pressure ulcer. Blanching erythema indicates that the skin is still viable and blood flow is present, which differentiates Stage I from more advanced stages of pressure injury.

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A nurse is assessing cranial nerve VIII.What tests will be administered on the client?

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Naxlex Comprehensive Predictor Exams

Which of the following is true in regards to hyperopia?

Correct Answer is C

Explanation

A patient has been admitted to the hospital after the staff at a nursing home noticed a pressure ulcer on his sacral area.The nurse examines the sacral ulcer and determines it is a Stage II ulcer.Which of these findings is characteristic of a Stage II pressure ulcer?

Correct Answer is ["B","E"]

Explanation

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A nurse is assessing cranial nerve VIII.
What tests will be administered on the client?