The nurse is assessing cranial nerve 5 (the trigeminal nerve) in a newly admitted client. What instruction should the nurse provide to the client during this phase of the assessment?

"Clench your teeth together tightly."

"Open your mouth wide and say 'ah.'"

"Look at me while I shine this light in your eye."

"Close your left eye and look at me with your right eye."

Answer and Explanation

The Correct Answer is A

Choice A reason: Clenching teeth tests cranial nerve V’s motor branch, innervating mastication muscles like the masseter. This assesses strength and symmetry, directly evaluating trigeminal function, making it the precise instruction for this nerve’s motor assessment accurately here.
Choice B reason: Opening the mouth and saying “ah” tests cranial nerves IX and X, not V. This assesses gag reflex and palate movement, missing the trigeminal’s role in jaw strength, rendering it irrelevant to this specific nerve exam fully.
Choice C reason: Shining light in the eye tests cranial nerves II and III, not V. This checks pupil response, unrelated to trigeminal sensory or motor functions, excluding it from the assessment of jaw and facial sensation entirely here.
Choice D reason: Closing one eye and looking tests cranial nerves III, IV, and VI, not V. This evaluates eye movement, not trigeminal innervation of facial muscles or sensation, disconnecting it from the intended cranial nerve assessment fully here.

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Correct Answer is A

Explanation

Choice A reason: Turning the head against resistance assesses neck muscles, not the temporomandibular joint (TMJ), which hinges the jaw. TMJ evaluation requires jaw-specific movements, not cervical rotation, indicating a misunderstanding of TMJ anatomy and function, misaligning with headache assessment needs.

Choice B reason: Opening the mouth wide while fingers are placed near the ear directly tests TMJ range of motion and joint integrity. This is a standard technique to detect dysfunction or pain, correctly targeting the jaw’s articulation point relevant to headaches.

Choice C reason: Moving the jaw side to side evaluates TMJ lateral excursion, a key diagnostic motion. Pain reporting during this action helps identify joint issues tied to chronic headaches, making it an appropriate and precise instruction for TMJ assessment.

Choice D reason: Pushing out and pulling in the jaw tests TMJ protrusion and retraction, critical for assessing joint stability and sounds like popping, which may link to headache etiology. This instruction correctly focuses on TMJ mechanics and symptoms.

A. 4+ B. 1+ C. 2+ D. 3+

Correct Answer is A

Explanation

Choice A reason: Tonsils touching the uvula indicate 4+ grading, where they obstruct over 75% of the oropharynx. This severe enlargement, with sore throat, fits the highest scale, reflecting significant inflammation or infection impacting airway and swallowing, accurately documented here.

Choice B reason: 1+ tonsils are slightly enlarged, less than 25% of the oropharynx, visible but not near the uvula. This underestimates the finding of tonsils contacting the uvula, misrepresenting the degree of obstruction and inflammation present in this case entirely.

Choice C reason: 2+ tonsils occupy 25-50% of the oropharynx, not touching the uvula. This moderate grade doesn’t match the observed contact, understating the severity of enlargement and potential airway compromise noted during the inspection clearly and significantly.

Choice D reason: 3+ tonsils cover 50-75% of the oropharynx, nearing but not contacting the uvula. This is close but inaccurate, as the finding shows full contact, warranting the higher 4+ grade for precise documentation of this advanced tonsillar size fully.

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The nurse is assessing cranial nerve 5 (the trigeminal nerve) in a newly admitted client. What instruction should the nurse provide to the client during this phase of the assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is working with a client who has a history of headaches for greater than two months. When preparing to assess the client's temporomandibular joint, what instruction provided to the client would indicate the nurse needs more teaching?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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