A nurse is assessing a client’s cranial nerves. Which methods should the nurse use to assess cranial nerve V?

Ask the client to clench their teeth and assess facial sensation.

Ask the client to identify scented aromas.

Ask the client to read a Snellen chart.

Ask the client to raise his eyebrows.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Cranial nerve V is the trigeminal nerve, which has both motor and sensory functions: Motor function: The nurse can assess this by asking the client to clench their teeth while palpating the masseter and temporalis muscles for strength. Sensory function: The nurse can assess this by lightly touching the client's face in different areas (forehead, cheeks, and jaw) with a cotton ball or sharp/dull object to check for sensation.

Choice B Reason:

Asking the client to identify scented aromas is a method used to assess cranial nerve I (Olfactory), not cranial nerve V. Cranial nerve V (Trigeminal) is assessed by testing facial sensation and motor functions such as chewing.

Choice C Reason:

Asking the client to read a Snellen chart is a method used to assess cranial nerve II (Optic), which is responsible for vision. This method does not assess cranial nerve V

Choice D Reason:

Asking the client to raise his eyebrows is a method used to assess cranial nerve VII (Facial), which controls facial expressions. This method is not used to assess cranial nerve V.

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Correct Answer is A

Explanation

Choice A reason: Positioning the collection device below the level of the chest is crucial to ensure proper drainage of air or fluid from the pleural space. This positioning uses gravity to facilitate drainage and prevent backflow into the pleural cavity, which could lead to complications such as pneumothorax or pleural effusion. The collection device should always be kept below the chest level to maintain effective drainage.

Choice B reason: Clamping the chest tube is generally not recommended unless specifically ordered by a physician or during certain procedures. Clamping can lead to a buildup of air or fluid in the pleural space, increasing the risk of tension pneumothorax. It is essential to keep the chest tube unclamped to allow continuous drainage and prevent complications.

Choice C reason: Applying an occlusive dressing over the chest tube site is necessary to prevent air from entering the pleural space and to secure the tube. However, this is not the primary action related to the positioning of the collection device. The occlusive dressing helps maintain the integrity of the chest tube insertion site and prevents infection.

Choice D reason: Emptying the chest tube collection chamber every shift is not a standard practice. The collection chamber should be monitored and emptied as needed based on the volume of drainage and the specific protocols of the healthcare facility. Regular monitoring is essential, but unnecessary emptying can disrupt the closed system and increase the risk of infection.

A. Hyperkalosis B. Hyponatremia C. Acidosis D. Alkalosis

Correct Answer is C

Explanation

Choice A Reason:

Hyperkalosis is incorrect. Hyperkalosis refers to an elevated level of potassium in the blood, which is not directly related to the pH level. While hyperkalemia can occur in acidosis, it is not the primary condition indicated by a low pH

Choice B Reason:

Hyponatremia is incorrect. Hyponatremia refers to low sodium levels in the blood. It does not directly affect the pH level and is not indicated by the pH value provided.

Choice C Reason:

Acidosis is correct. The normal pH range for arterial blood is 7.35 to 7.45. A pH of 7.10 is below this range, indicating that the blood is too acidic. This condition is known as acidosis.

Choice D Reason:

Alkalosis is incorrect. Alkalosis refers to a condition where the blood pH is higher than the normal range, indicating that the blood is too basic. A pH of 7.10 is too low, not too high, and therefore indicates acidosis.

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A nurse is assessing a client’s cranial nerves. Which methods should the nurse use to assess cranial nerve V?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a chest tube. Which action should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who had an arterial blood gas drawn. The pH on the ABG is 7.10. What acid-base imbalance does this client have?

Correct Answer is C

Explanation

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