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 ["A","C","D"]

Explanation

A) Trochlear: The trochlear nerve (CN IV) is responsible for innervating the superior oblique muscle, which helps control the downward and inward movement of the eye.
B) Optic: The optic nerve (CN II) is primarily involved in vision and visual acuity, not in the movement of the eye. It transmits visual information from the retina to the brain.
C) Oculomotor: The oculomotor nerve (CN III) controls most of the extraocular muscles, including those responsible for eye movement (superior rectus, inferior rectus, medial rectus, and inferior oblique) and also controls pupil constriction.
D) Abducens: The abducens nerve (CN VI) controls the lateral rectus muscle, which is responsible for the outward movement of the eye.
E) Facial: The facial nerve (CN VII) controls the muscles of facial expression and is not involved in eye movements.

A. "Let's stop and take your vital signs." B. "We can take a break anytime." C. "Keep taking deep breathes; you will be okay." D. "Let's stop: I have all of the information we need."

Correct Answer is D

Explanation

A) "Let's stop and take your vital signs": While taking vital signs can be important, it might not address the immediate discomfort the client is experiencing from the deep palpation. This response may not fully address the need to pause the assessment in light of the client’s discomfort.
B) "We can take a break anytime": Offering a break is considerate, but it does not directly address the immediate situation. If the client is already in significant discomfort, it's more appropriate to stop the procedure entirely if the information gathered so far is sufficient.
C) "Keep taking deep breaths; you will be okay": Encouraging deep breathing may help manage some discomfort, but it doesn’t acknowledge the client's need to stop the procedure or the fact that the assessment may have already provided sufficient information.
D) "Let's stop: I have all of the information we need": Stopping the palpation when the client is experiencing pain or discomfort and when enough information has been obtained is the most appropriate response. It shows sensitivity to the client's pain and prioritizes their comfort, while also acknowledging that the assessment may have achieved its purpose.

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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

Which cranial nerves are involved in eye movements? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

The nurse uses deep palpation of the abdomen to assess the client for presence of an abdominal mass. The client grimaces and grips the hand rails of the bed. Which response by the nurse is best?

Correct Answer is D

Explanation

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