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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Slow venous return causes edema, not deep, painful wounds. This venous issue lacks the arterial insufficiency link to tissue necrosis, misaligning with the circular ulcer’s ischemic profile, which requires oxygen delivery, not just drainage, here fully.

Choice B reason: Osmotic pressure disruption affects fluid balance, not localized wounds. This systemic issue doesn’t explain a toe ulcer’s depth and pain, missing the vascular supply deficit driving tissue breakdown in this specific extremity finding entirely and clearly.

Choice C reason: Lymphatic blockage or infection causes swelling or lymphangitis, not deep, circular wounds. This lacks the ischemic etiology of toe ulcers, which stem from arterial insufficiency, not lymphatic dysfunction, distinguishing it from the observed pathology here fully.

Choice D reason: Inadequate arterial blood supply, as in peripheral artery disease, causes deep, painful toe ulcers due to tissue ischemia. Poor oxygen delivery leads to necrosis, matching the wound’s characteristics, making this the most likely etiology accurately and precisely.

A. Ischemic stroke B. Trigeminal neuralgia C. Meningitis D. Bell's palsy

Correct Answer is C

Explanation

Choice A reason: Ischemic stroke causes focal deficits like weakness, not neck flexion-induced leg pain. This vascular event lacks meningeal irritation signs, misaligning with the positive Brudzinski’s sign of knee bending and neck pain in this assessment fully here.
Choice B reason: Trigeminal neuralgia triggers facial pain, not leg or neck pain with flexion. This cranial nerve V issue doesn’t involve meningeal inflammation, excluding it from the systemic response seen in this neck maneuver entirely and accurately here.
Choice C reason: Meningitis causes meningeal irritation; neck flexion (Brudzinski’s sign) elicits leg pain and knee bending. Neck pain aligns with inflammation, making this the likely diagnosis for the client’s response to this specific neurological test comprehensively here.
Choice D reason: Bell’s palsy affects cranial nerve VII, causing facial paralysis, not leg or neck pain. This peripheral nerve issue lacks the meningeal signs triggered by neck flexion, ruling it out as the cause in this scenario fully here.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

The nurse's inspection of a client's extremities reveals a deep, circular, painful wound on the client's great toe. What should the nurse suspect as the etiology of the client's wound?

Correct Answer is D

Explanation

The nurse has placed her hands behind the client's head and flexed his neck forward as far as he can tolerate. During the test the client experiences leg pain and bends his knees. In addition, he complains of neck pain. This assessment finding is suggestive of what health problem?

Correct Answer is C

Explanation

An older adult client has been admitted due to decreased cognition. What assessment finding is most suggestive of delirium as the cause of the client's cognitive impairment?

A nurse is caring for a client who has presbycusis. Which of the following actions should the nurse take?

A client has sought care because of a sudden increase in the size of his scrotum after a cough. The nurse's assessment reveals the presence of a large scrotal mass. How can the nurse best assess for a scrotal hernia?

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiologic process in the lungs?

A nurse is providing a subjective data assessment for an older female. The client verbalizes a list of symptoms regarding their concern. Which findings would lead the nurse to supply education about menopause?

When performing a genitourinary assessment of an older male patient, the nurse notes that the urethral meatus is positioned dorsally. What is the most important concern the nurse identifies from their assessment?

A client is seeking medical help due to loss of central vision. What diagnosis might the nurse suspect?

The nursing preceptor is observing the nursing student providing a neurological assessment focusing on various tests for cerebellar function. What would be the priority test the preceptors should expect the student to perform on their client?