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

The correct answer is d) Tighten the abdominal muscles while exhaling.

Choice A Reason:

“Raise both shoulders while breathing deeply” is incorrect. Diaphragmatic breathing focuses on using the diaphragm rather than the shoulders. Raising the shoulders can lead to shallow chest breathing, which is less effective for oxygen exchange.

Choice B Reason:

“Inhale through the mouth” is incorrect. For diaphragmatic breathing, it is recommended to inhale through the nose. This helps filter, warm, and humidify the air before it reaches the lungs.

Choice C Reason:

“Exhale through the nose” is incorrect. While exhaling through the nose is beneficial in some breathing exercises, diaphragmatic breathing typically involves exhaling through pursed lips. This technique helps slow down the exhalation and keeps the airways open longer.

Choice D Reason:

“Tighten the abdominal muscles while exhaling” is correct. Tightening the abdominal muscles helps push the diaphragm up, forcing air out of the lungs more efficiently. This action is a key component of effective diaphragmatic breathing.

Choice A Reason:

The client’s immediate family members may not always have the right to access the client’s protected health information (PHI) unless the client has given explicit consent. Confidentiality laws, such as the Health Insurance Portability and Accountability Act (HIPAA) in the United States, are designed to protect the privacy of patients’ health information. These laws generally require that PHI be shared only with individuals who are directly involved in the patient’s care or who have been authorized by the patient. Therefore, while family members may be involved in the patient’s care, they do not automatically have the right to access PHI without the patient’s consent.

Choice B Reason:

The facility’s administrators typically do not need access to a specific client’s PHI unless it is necessary for administrative purposes related to the patient’s care or for compliance with legal and regulatory requirements. Administrators are generally more involved in the overall management and operation of the healthcare facility rather than in the direct care of individual patients. Sharing PHI with administrators without a valid reason could violate confidentiality laws and the patient’s right to privacy.

Choice C Reason:

Health care team members caring for the client are directly involved in the patient’s care and, therefore, have a legitimate need to access the client’s PHI. This includes doctors, nurses, therapists, and other healthcare professionals who are providing treatment, coordinating care, or ensuring the patient’s well-being. Sharing PHI with these individuals is essential for delivering safe and effective care, and it is permitted under confidentiality laws such as HIPAA.

Choice D Reason:

Clergy affiliated with the facility may provide spiritual support to patients, but they do not typically have a legitimate need to access the client’s PHI unless the patient has given explicit consent. While spiritual care is an important aspect of holistic healthcare, it does not require access to detailed medical information. Therefore, sharing PHI with clergy without the patient’s consent would generally be considered a violation of confidentiality laws.