A nurse is performing a neurological assessment for a client who has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?
Ask the client to shrug his shoulders against passive resistance
Instruct the client to look up and down without moving his head
Observe the client's ability to smile and frown
Have the client stand with his eyes closed and touch his nose
The Correct Answer is B
Choice A: Ask the client to shrug his shoulders against passive resistance is not an assessment that will give the nurse information about the function of cranial nerve III. This assessment will test the function of cranial nerve XI, which is the accessory nerve. The accessory nerve innervates the trapezius and sternocleidomastoid muscles, which are involved in shoulder and neck movements.
Choice B: Instruct the client to look up and down without moving his head is an assessment that will give the nurse information about the function of cranial nerve III. Cranial nerve III is the oculomotor nerve, which innervates four of the six extraocular muscles that control eye movements. The oculomotor nerve also controls pupil size and lens shape. By instructing the client to look up and down without moving his head, the nurse can assess the ability of the oculomotor nerve to move the eyes vertically and adjust to different distances.
Choice C: Observe the client's ability to smile and frown is not an assessment that will give the nurse information about the function of cranial nerve III. This assessment will test the function of cranial nerve VII, which is the facial nerve. The facial nerve innervates the muscles of facial expression, which are involved in smiling, frowning, blinking, and other facial movements.
Choice D: Have the client stand with his eyes closed and touch his nose is not an assessment that will give the nurse information about the function of cranial nerve III. This assessment will test the function of cranial nerve VIII, which is the vestibulocochlear nerve. The vestibulocochlear nerve innervates the inner ear and is responsible for hearing and balance. By having the client stand with his eyes closed and touch his nose, the nurse can assess the ability of the vestibulocochlear nerve to maintain equilibrium and coordination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: This is incorrect. Widening pulse pressure is not a sign of hypovolemic shock, but rather of increased intracranial pressure or aortic regurgitation. Hypovolemic shock causes narrowing pulse pressure due to decreased stroke volume and increased peripheral resistance.
Choice B Reason: This is correct. Increased heart rate is a sign of hypovolemic shock, as the body tries to compensate for the decreased blood volume and cardiac output by increasing the heart rate and contractility.
Choice C Reason: This is incorrect. Increased deep tendon reflexes are not a sign of hypovolemic shock, but rather of hyperreflexia or tetany. Hypovolemic shock causes decreased deep tendon reflexes due to reduced perfusion and oxygenation of the muscles and nerves.
Choice D Reason: This is incorrect. Pulse oximetry 96% is not a sign of hypovolemic shock, but rather of normal oxygen saturation. Hypovolemic shock causes decreased pulse oximetry due to hypoxia and impaired gas exchange.
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because dabigatran does not affect the electrical activity of the heart or the conduction system. It does not slow down the ventricular response to the atrial impulses.
Choice B Reason: This is incorrect because dabigatran does not dissolve existing clots in the bloodstream. It only prevents new clots from forming.
Choice C Reason: This is correct because dabigatran reduces the risk of stroke in clients who have atrial fibrillation by preventing clot formation and reducing blood viscosity. Dabigatran is an anticoagulant medication that prevents the formation of blood clots in the heart and blood vessels. Atrial fibrillation is a condition where the atria beat irregularly and rapidly, which can cause blood to pool and clot in the heart chambers. These clots can travel to the brain and cause a stroke. Dabigatran reduces the risk of stroke by preventing clot formation and reducing blood viscosity.
Choice D Reason: This is incorrect because dabigatran does not restore normal sinus rhythm in clients who have atrial fibrillation. It does not affect the heart rate or rhythm.
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