A nurse is collecting data about a client's cranial nerves. Which of the following methods should the nurse use to identify a problem with cranial nerve II?
Assess the 6 cardinal gazes
Ask the client to her clench teeth.
Anticipate the use of a tonometer
Use a Snellen chart.
The Correct Answer is D
a) Assess the 6 cardinal gazes: This test assesses cranial nerve III, IV, and VI (oculomotor, trochlear, and abducens), which control eye movement, not the optic nerve.
b) Ask the client to clench teeth: This tests cranial nerve V (trigeminal nerve), which controls sensation in the face and motor functions like chewing.
c) Anticipate the use of a tonometer: A tonometer measures intraocular pressure (IOP), which is related to glaucoma, but it does not specifically assess cranial nerve II.
d) Use a Snellen chart: The Snellen chart is used to test visual acuity, which evaluates the function of cranial nerve II (optic nerve).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a) Has no serious complications: Bacterial pharyngitis, especially streptococcal pharyngitis, can have serious complications, such as rheumatic fever or glomerulonephritis, which are not seen with viral pharyngitis.
b) Presents a negative culture: Bacterial pharyngitis typically presents with a positive throat culture for bacteria, while viral pharyngitis typically shows a negative culture.
c) Has an abrupt onset: Bacterial pharyngitis often has a sudden and severe onset of symptoms, while viral pharyngitis tends to have a more gradual onset.
d) Presents a normal complete blood count (CBC): In bacterial pharyngitis, the CBC may show an elevated white blood cell count, while in viral pharyngitis, the CBC may remain normal or slightly elevated.
Correct Answer is D
Explanation
a) Encourage increased fluid intake: In acute glomerulonephritis, fluid retention is common due to kidney dysfunction, so increasing fluid intake can exacerbate symptoms like edema and hypertension.
b) Encourage frequent ambulation: While ambulation is important for overall health, excessive activity may worsen symptoms such as fatigue or edema in clients with acute glomerulonephritis. Rest and limited activity are often recommended initially.
c) Obtain weekly weight: For a client with acute glomerulonephritis, weight monitoring should ideally be done daily. This allows for more precise tracking of fluid balance and early detection of fluid retention or weight gain, which could indicate worsening of the condition.
d) Place the client on a low-sodium diet: A low-sodium diet helps reduce fluid retention and lower blood pressure, which are important in managing acute glomerulonephritis and preventing complications such as edema or hypertension.
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