A nurse is preparing to assess a client. Which action should the nurse take to check cranial nerve VI?

Open the client’s visual acuity using a Snellen chart.

Whisper none of the client’s ears while blocking the other.

Ask the client to inspect up.

Ask the client to smile.

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Open the client’s visual acuity using a Snellen chart is incorrect. This action assesses cranial nerve II (optic nerve), which is responsible for vision. The Snellen chart is used to measure visual acuity, not the function of cranial nerve VI

Choice B Reason:

Whisper none of the client’s ears while blocking the other is incorrect. This action assesses cranial nerve VIII (vestibulocochlear nerve), which is responsible for hearing and balance. Whispering tests the auditory function of this nerve.

Choice C Reason:

Ask the client to inspect up is correct. Cranial nerve VI (abducens nerve) controls the lateral rectus muscle, which is responsible for moving the eye outward. Asking the client to look up and outward helps assess the function of this nerve.

Choice D Reason:

Ask the client to smile is incorrect. This action assesses cranial nerve VII (facial nerve), which controls the muscles of facial expression. Smiling tests the motor function of this nerve.

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Correct Answer is A

Explanation

Choice A Reason:

Sclera is correct. The sclera, or the white part of the eye, is a reliable site to assess for jaundice, especially in dark-skinned individuals. Jaundice causes a yellowish discoloration of the sclera due to the accumulation of bilirubin in the blood. This yellowing is often more noticeable in the sclera than in other parts of the body.

Choice B Reason:

Dorsal surface of the foot is incorrect. The dorsal surface of the foot is not a reliable site for assessing jaundice, particularly in dark-skinned individuals. The skin on the feet may not show the yellow discoloration as clearly as the sclera.

Choice C Reason:

Pinnae of the ears is incorrect. The pinnae, or outer parts of the ears, are not typically used to assess for jaundice. The skin in this area may not show the yellow discoloration as effectively as the sclera.

Choice D Reason:

Palmar surface of the hand is incorrect. While the palms can sometimes show signs of jaundice, they are not as reliable as the sclera. The yellow discoloration may be less noticeable on the palms, especially in dark-skinned individuals.

A. Do not take the medication before bedtime. B. Take the medication with a full glass of water. C. This medication must be taken on an empty stomach. D. Expect abdominal pain with this medication.

Correct Answer is B

Explanation

Choice A Reason:

“Do not take the medication before bedtime” is incorrect because the timing of medication administration depends on the specific medication and its intended effects. Some medications are specifically prescribed to be taken at bedtime to help with sleep or to reduce side effects that might occur during the day.

Choice B Reason:

“Take the medication with a full glass of water” is correct because many medications require adequate hydration to ensure proper absorption and to prevent irritation of the esophagus and stomach. Taking medication with a full glass of water helps to ensure that the medication reaches the stomach quickly and reduces the risk of esophageal irritation or damage.

Choice C Reason:

“This medication must be taken on an empty stomach” is incorrect unless the specific medication requires it. Some medications are better absorbed on an empty stomach, but this is not a universal rule and depends on the medication’s formulation and intended use.

Choice D Reason:

“Expect abdominal pain with this medication” is incorrect because not all medications cause abdominal pain. If a medication is known to cause abdominal pain, the nurse should provide additional instructions on how to manage this side effect or discuss alternative medications with the healthcare provider.

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A nurse is preparing to assess a client. Which action should the nurse take to check cranial nerve VI?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing for jaundice on a dark-skinned client. Which site should the nurse examine to identify jaundice on this client?

Correct Answer is A

Explanation

A nurse is teaching a client who is taking medication before bedtime. The nurse should include the following instructions:

Correct Answer is B

Explanation

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