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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A Reason:
Date of birth is an acceptable client identifier. The Joint Commission specifies that using the date of birth helps ensure accurate identification of the client. This identifier is unique to each individual and is less likely to be duplicated.
Choice B Reason:
Photograph identification is not typically listed as an acceptable identifier by the Joint Commission. While it can be useful in some settings, it is not one of the primary identifiers recommended for ensuring patient safety.
Choice C Reason:
Facility room number is not an acceptable client identifier. The Joint Commission explicitly states that room numbers should not be used as identifiers because they can change and are not unique to the individual.
Choice D Reason:
Client’s full name is an acceptable client identifier. Using the full name helps to accurately identify the client and match them with their medical records and treatment plans.
Correct Answer is D
Explanation
Choice A Reason:
“Delivers a low concentration of oxygen” is incorrect because a nasal cannula can deliver varying concentrations of oxygen depending on the flow rate set by the healthcare provider. The concentration can range from low to moderate, typically between 24% to 44%.
Choice B Reason:
“Delivers a constant rate of oxygen” is partially correct but not entirely accurate. While the flow rate can be constant, the key aspect is the specific concentration of oxygen delivered, which is more relevant to the client’s understanding.
Choice C Reason:
“Delivers a high concentration of oxygen” is incorrect because nasal cannulas are generally used for low to moderate oxygen delivery. High concentrations of oxygen are typically delivered through other devices like non-rebreather masks or high-flow nasal cannulas.
Choice D Reason:
“Delivers a constant flow of a specific concentration of oxygen” is correct. This explanation accurately describes how a nasal cannula works. It provides a continuous flow of oxygen at a specific concentration, which is adjusted based on the client’s needs and the healthcare provider’s prescription.
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