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?

Choice A Reason: This is incorrect because turning off the lights and TV and closing the door may increase the client's anxiety and confusion. The nurse should provide adequate lighting and familiar objects to help orient the client.

Choice B Reason: This is incorrect because using restraints may increase the risk of injury, infection, and psychological distress for the client. The nurse should use restraints only as a last resort and with a physician's order.

Choice C Reason: This is incorrect because asking for a sedative may not address the underlying cause of the agitation. The nurse should use non-pharmacological interventions first, such as calming music, massage, or aromatherapy.

Choice D Reason: This is correct because identifying the cause of the agitation may help resolve it. The nurse should assess for possible triggers, such as pain, hunger, thirst, infection, or environmental factors.

Choice A reason: This is incorrect because the nurse should not include this in teaching. Massaging the affected side multiple times a day can trigger an acute onset of trigeminal neuralgia. Trigeminal neuralgia is a condition that causes severe pain in one or more branches of the trigeminal nerve (cranial nerve V), which innervates the face. The pain can be triggered by touch, pressure, or movement of the face. The nurse should advise the client to avoid touching or stimulating the affected side.

Choice B reason: This is incorrect because the nurse should not include this in teaching. Applying ice directly to
the skin can trigger an acute onset of trigeminal neuralgia. Trigeminal neuralgia can be triggered by temperature changes or cold stimuli on the face. The nurse should advise the client to avoid exposure to cold air or wind and to protect their face with a scarf or mask.

Choice C reason: This is incorrect because the nurse should not include this in teaching. Providing pureed consistency foods can trigger an acute onset of trigeminal neuralgia. Trigeminal neuralgia can be triggered by chewing, swallowing, or talking. The nurse should advise the client to eat soft foods that do not require much chewing and to avoid hot or spicy foods that can irritate the mouth.

Choice D reason: This is correct because the nurse should include this in teaching. Considering alternative therapies such as yoga, biofeedback or meditation can help prevent triggering an acute onset of trigeminal neural