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 C

Explanation

Choice A Reason: This choice is incorrect. Inability to perform within normal limits is a vague and general term that does not describe the specific finding of left facial droop. The nurse should document the exact observation and compare it to the expected or normal range.

Choice B Reason: This choice is incorrect. Symmetrical findings mean that both sides of the body or face are equal or similar in appearance or function. Left facial droop indicates that one side of the face is lower or weaker than the other, which is not symmetrical.

Choice C Reason: This is the correct choice. Asymmetrical findings mean that both sides of the body or face are unequal or different in appearance or function. Left facial droop indicates that one side of the face is lower or weaker than the other, which is asymmetrical.

Choice D Reason: This choice is incorrect. Bilateral strength present means that both sides of the body or face have normal or adequate muscle power or force. Left facial droop indicates that one side of the face has reduced or impaired muscle power or force, which is not bilateral strength present.

A. Slow even breathing B. Bradycardia and bounding pulse C. Systolic hypotension with a narrowing pulse pressure D. Irregular respirations E. Tachycardia and bounding pulse F. Systolic hypertension with a widening pulse pressure

Correct Answer is ["B","D","F"]

Explanation

Choice A Reason: Slow even breathing is not a sign of Cushing's Triad, which is a late indicator of increased intracranial pressure (ICP). The breathing pattern may be altered due to brainstem compression, but not necessarily slow or even.

Choice B Reason: This is a correct answer because bradycardia and bounding pulse are part of Cushing's Triad, which reflects an increased vagal tone and decreased cardiac output due to increased ICP.

Choice C Reason: Systolic hypotension with a narrowing pulse pressure is not a sign of Cushing's Triad, which involves an increased systolic blood pressure and a widened pulse pressure due to increased ICP. Hypotension may occur due to shock or hemorrhage, but not as a result of increased ICP.

Choice D Reason: This is a correct answer because irregular respirations are part of Cushing's Triad, which reflects impaired respiratory control due to brainstem compression from increased ICP. The respirations may be Cheyne-Stokes, central neurogenic hyperventilation, apneustic, or ataxic.

Choice E Reason: Tachycardia and bounding pulse are not signs of Cushing's Triad, which involves bradycardia and bounding pulse due to increased ICP. Tachycardia may occur due to pain, anxiety, fever, or hypoxia, but not as a result of increased ICP.

Choice F Reason: This is a correct answer because systolic hypertension with a widening pulse pressure are part of Cushing's Triad, which reflects an increased cerebral perfusion pressure due to increased ICP. The diastolic blood pressure remains stable or decreases, resulting in a widened pulse pressure.

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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

When performing an assessment, the nurse observes for bilateral equality. After performing a neurological assessment, which of the following will the nurse document when assessment findings indicate that there is left facial droop?

Correct Answer is C

Explanation

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Correct Answer is ["B","D","F"]

Explanation

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