A nurse is performing a focused assessment for vision on a client suspected of having vision loss. Which cranial nerve is the nurse assessing when determining if there are visual field or visual acuity deficits?

Cranial Nerve VIII

Cranial Nerve II

Cranial Nerve I

Cranial Nerve VII

Answer and Explanation

The Correct Answer is B

Choice A Reason: This choice is incorrect. Cranial Nerve VIII is the vestibulocochlear nerve, which is responsible for hearing and balance. It does not affect vision or eye movements.

Choice B Reason: This is the correct choice. Cranial Nerve II is the optic nerve, which is responsible for transmitting visual information from the retina to the brain. It affects visual field and visual acuity, which are measures of peripheral and central vision, respectively.

Choice C Reason: This choice is incorrect. Cranial Nerve I is the olfactory nerve, which is responsible for smell. It does not affect vision or eye movements.

Choice D Reason: This choice is incorrect. Cranial Nerve VII is the facial nerve, which is responsible for facial expressions and taste. It does not affect vision or eye movements.

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Correct Answer is A

Explanation

Choice A Reason: This is correct because first degree burns are superficial burns that affect only the outer layer of the skin, called the epidermis. First degree burns cause redness, pain, and mild swelling, but no blisters or scarring. They usually heal within a week.

Choice B Reason: This is incorrect because second degree burns are partial thickness burns that affect both the epidermis and the underlying layer of the skin, called the dermis. Second degree burns cause blisters, severe pain, and possible infection. They may take several weeks to heal and may leave scars.

Choice C Reason: This is incorrect because third degree burns are full thickness burns that destroy all layers of the skin and may damage the underlying tissues, such as muscles, nerves, or bones. Third degree burns cause charred or white skin, numbness, and shock. They require skin grafting and may cause permanent disability or death.

Choice D Reason: This is incorrect because this burn can be classified according to the depth and extent of the skin damage. The classification of burns helps to determine the appropriate treatment and prognosis for the client.

A. Soft pasty stool is noted in the collection device B. There is purple discoloration of the stoma C. Stoma is beefy red D. There is skin excoriation around the stoma

Correct Answer is B

Explanation

Choice A Reason: Soft pasty stool is normal for a transverse colostomy, as the stool has not reached the sigmoid colon where most of the water is absorbed.

Choice B Reason: This is the correct answer because purple discoloration of the stoma indicates ischemia or necrosis, which can lead to infection, perforation, or sepsis. It requires urgent intervention.

Choice C Reason: Stoma is beefy red is a normal finding for a healthy stoma, as it indicates adequate blood supply and healing.

Choice D Reason: There is skin excoriation around the stoma is a common complication of a colostomy, as the stool can irritate the skin. It can be managed with proper skin care and appliance fitting.

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A nurse is performing a focused assessment for vision on a client suspected of having vision loss. Which cranial nerve is the nurse assessing when determining if there are visual field or visual acuity deficits?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client arrives to the clinic after spending the day at the beach. She reports extreme pain and the nurse observes red skin on her face and upper body. There are no blisters present. What degree of burn has the client suffered?

Correct Answer is A

Explanation

The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the primary health care provider?

Correct Answer is B

Explanation

The results of a client's audiogram indicate that the client has hearing at 15 decibels (dB). What action should the nurse take when communicating to the client?

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