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 D

Explanation

Choice A reason: Cerebral stagger isn’t a standard term; cerebral damage might cause spasticity, not wide-based ataxia. This lacks specificity for cerebellar signs like staggering, misaligning with the broad, unsteady gait tied to coordination loss in this client fully.
Choice B reason: Scissors gait, from cerebral palsy, shows stiff, crossed legs, not wide-based staggering. This spastic pattern contrasts with the unsteady, broad stance of cerebellar dysfunction, excluding it as the correct description for this presentation entirely here.
Choice C reason: Parkinsonian gait is shuffling with small steps and rigidity, not wide-based or staggering. This contrasts with the unsteady, broad stance of cerebellar ataxia, making it an incorrect match for the client’s observed walking pattern fully here.
Choice D reason: Cerebellar ataxia causes a wide-based, staggering gait due to coordination loss from cerebellar damage. This matches the client’s unsteady walk, reflecting impaired balance and motor control, accurately describing the observed gait pattern comprehensively here.

A. Prolonged tonsillar enlargement B. History of allergies C. Incomplete immunization record D. History of epistaxis nosebleeds

Correct Answer is B

Explanation

Choice A reason: Prolonged tonsillar enlargement may cause throat issues or obstruction, but rhinorrhea stems from nasal inflammation, not tonsils. This focuses on oropharyngeal anatomy, missing the direct nasal etiology tied to runny nose in upper airway complaints here entirely.

Choice B reason: Allergies trigger nasal inflammation via histamine, causing rhinorrhea as IgE-mediated mast cells release mediators. A history of this is key, directly linking environmental triggers to the client’s runny nose, making it the most relevant assessment area accurately.

Choice C reason: Incomplete immunizations increase infection risk, but rhinorrhea more commonly ties to allergies or viruses than vaccine-preventable diseases here. This is less specific to the symptom’s etiology without fever or systemic signs, reducing its pertinence significantly.

Choice D reason: Epistaxis (nosebleeds) relates to vascular fragility, not mucus production like rhinorrhea. Past bleeding doesn’t explain runny nose, focusing on a separate nasal issue, making it less relevant to the upper airway complaint’s root cause in this case 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 client with a wide-based, staggering, unsteady gait walks into the clinic. The gait would be correctly described as which of the following?

Correct Answer is D

Explanation

A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea?

Correct Answer is B

Explanation

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