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 D

Explanation

Choice A Reason: This is incorrect because earphones are not used in the Rinne test. The Rinne test compares air conduction and bone conduction of sound using a tuning fork.

Choice B Reason: This is incorrect because electrodes are not used in the Rinne test. Electrodes are used in electroencephalography (EEG), which measures brain activity.

Choice C Reason: This is incorrect because a probe is not used in the Rinne test. A probe is used in tympanometry, which measures the pressure and mobility of the eardrum.

Choice D Reason: This is correct because a tuning fork is used in the Rinne test. The tuning fork is placed on the mastoid process behind the ear and then moved near the ear canal to compare the sound perception.

A. Observe the client swallowing small sips of water before assisting with feeding B. Turn on the television for the client during meals C. Instruct the client to tilt their head back while swallowing D. Sit the client upright 90 degrees then assist the client with feeding

Correct Answer is D

Explanation

Choice A Reason: This is incorrect because observing the client swallowing small sips of water before assisting with feeding may not reduce the risk of aspiration pneumonia. Water is a thin liquid that can easily enter the lungs if the client has impaired swallowing or cough reflexes. The nurse should assess the client's need for thickened liquids or pureed foods and use a swallow screening tool to determine the appropriate consistency and amount of food and fluids.

Choice B Reason: This is incorrect because turning on the television for the client during meals may increase the risk of aspiration pneumonia. Television can distract the client from focusing on chewing and swallowing and cause them to eat too fast or too much. The nurse should provide a quiet and calm environment for the client during meals and encourage them to eat slowly and carefully.

Choice C Reason: This is incorrect because instructing the client to tilt their head back while swallowing may increase the risk of aspiration pneumonia. Tilting the head back can open the airway and allow food or fluids to enter the lungs. The nurse should instruct the client to tilt their head forward or tuck their chin while swallowing, which can close the airway and prevent aspiration.

Choice D Reason: This is correct because sitting the client upright 90 degrees then assisting the client with feeding can reduce the risk of aspiration pneumonia. Sitting upright can help gravity move food and fluids down the esophagus and away from the lungs. The nurse should also keep the client upright for at least 30 minutes after eating and drinking to prevent regurgitation and aspiration.

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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 nurse is teaching a client about the Rinne test. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is caring for a client who has dementia. Which of the following actions should the nurse take to reduce the client's risk of aspiration pneumonia?

Correct Answer is D

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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