How would the nurse assess CN VIII Acoustic, vestibulocochlear: Select all that Apply

Weber test

Magazine

Rhine test

Whispered voice test

Answer and Explanation

Correct Answer : A,C,D

A. Weber test: The Weber test is used to assess hearing by placing a vibrating tuning fork on the center of the forehead. It helps evaluate lateralization of sound and can indicate whether hearing loss is conductive or sensorineural. This test is pertinent for assessing CN VIII, which is responsible for hearing.
B. Magazine: This option is not relevant to the assessment of CN VIII. A magazine is not used in evaluating hearing or vestibular function. The appropriate assessments for CN VIII focus on hearing and balance.
C. Rinne test: The Rinne test involves placing a vibrating tuning fork on the mastoid bone and then near the ear canal to compare air conduction (AC) and bone conduction (BC) of sound. This test helps differentiate between conductive and sensorineural hearing loss and is directly related to assessing CN VIII.
D. Whispered voice test: This test involves the nurse whispering numbers or words while occluding one ear and assessing the client's ability to hear and repeat them. It is a simple way to assess hearing ability and thus evaluates the function of CN VIII.

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Correct Answer is C

Explanation

A) Right knee +1; Left knee 0: The scale for grading reflexes typically ranges from 0 to 4. A score of 0 indicates no reflex, which does not align with the description of having a diminished but not absent reflex. A score of +1 suggests a reduced but present reflex, which would be appropriate for a diminished reflex on the left side.

B) Right knee +3; Left knee +2: A score of +3 indicates an exaggerated or brisk reflex, while +2 denotes a normal reflex. Since the right knee reflex is normal, it should be documented as +2. A diminished reflex on the left side is more accurately reflected by a score of +1, not +2.
C) Right knee +2; Left knee +1: This is the most accurate documentation. A score of +2 denotes a normal reflex, which applies to the right knee. A score of +1 reflects a diminished reflex, which is appropriate for the left knee where the reflex is present but reduced.
D) Right knee +4; Left knee +3: A score of +4 represents a very brisk or hyperactive reflex, which is not consistent with a normal finding. Similarly, a score of +3 would indicate an exaggerated reflex, which does not fit the description of the right knee being normal. The correct grading for a normal reflex is +2, and for a diminished reflex is +1.

A. Romberg test B. Rapid alternating movement test C. Tinel test D. Allen test

Correct Answer is D

Explanation

A) Romberg test: The Romberg test is used to assess a person’s balance and proprioception by asking them to stand with their eyes closed. It does not evaluate the patency of the ulnar and radial arteries.
B) Rapid alternating movement test: The rapid alternating movement test evaluates motor function and coordination by asking the patient to perform tasks like rapidly alternating hand movements. This test is not related to assessing arterial patency.
C) Tinel test: The Tinel test is used to detect nerve compression or irritation by tapping over a nerve, such as the median nerve at the wrist, to see if it elicits a tingling sensation. It does not assess the patency of the ulnar and radial arteries.
D) Allen test: The Allen test is specifically designed to evaluate the patency of the ulnar and radial arteries. It involves occluding both arteries at the wrist while the patient makes a fist and then releasing one artery to assess blood flow to the hand. This test ensures that there is adequate blood supply to the hand if one of the arteries is compromised.

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How would the nurse assess CN VIII Acoustic, vestibulocochlear: Select all that Apply

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Naxlex Comprehensive Predictor Exams

A client's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding?

Correct Answer is C

Explanation

The test done to evaluate and compare the patency of the ulnar and radial arteries is:

Correct Answer is D

Explanation

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