The nurse is assessing cranial nerves 3, 4 and 6 (oculomotor, trochlear and abducens). Which technique might the nurse use to assess all three in one technique?

Use an ophthalmoscope to view the optic disc and retina.

Have the client move his eyes in the 6 cardinal fields of gaze.

Use a tuning fork to see if the client can sense vibration on the closed eyelids bilaterally.

Have the client turn his head to track the nurse's hand movement as it makes a 360 curve around the client's head.

Answer and Explanation

The Correct Answer is B

Choice A reason: Ophthalmoscopy checks cranial nerve II (optic), not III, IV, or VI. It visualizes the retina, missing the eye movement control these nerves govern, making it irrelevant to their motor function assessment entirely here fully.
Choice B reason: The 6 cardinal fields test cranial nerves III (eye movement, pupil), IV (superior oblique), and VI (lateral rectus). This single technique evaluates all three by tracking coordinated eye motion, making it the most efficient method accurately here.
Choice C reason: Vibration on eyelids tests sensation, possibly cranial nerve V, not III, IV, or VI. These nerves control eye movement, not sensory input, excluding this from assessing their motor roles in this neurological exam fully here.
Choice D reason: Head turning with hand tracking involves neck muscles and possibly cranial nerve XI, not just III, IV, VI. This dilutes focus on eye-specific movements, making it less precise for these cranial nerves’ assessment entirely here.

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Correct Answer is D

Explanation

Choice A reason: Turbulence in large airways causes coarse sounds, not high-pitched wheezes. Wheezes stem from narrowed smaller passages, like bronchioles, not broad airway dynamics, making this less accurate for the specific sound’s pathophysiology fully here.
Choice B reason: Air leaking into the pleural space (pneumothorax) reduces breath sounds, not causing wheezes. Wheezes arise from airway narrowing, not alveolar rupture, excluding this as the source of the auscultated adventitious sound entirely here fully.
Choice C reason: Air diversion from trachea to bronchi is normal airflow, not producing wheezes. Wheezes require obstruction or constriction in smaller airways, not tracheal branching, rendering this unrelated to the sound’s pathological origin comprehensively here.
Choice D reason: Wheezes result from constricted respiratory passages, like in asthma, where narrowed bronchioles vibrate with airflow. This high-pitched sound matches the pathophysiology of airway narrowing, making it the correct explanation for this finding accurately here.

A. Facilitate blood testing for human immunodeficiency virus (HIV) B. Refer the client to a primary care provider for prescriptive medication C. Assess the client for signs of jaundice D. Assess the client's laboratory values for zinc deficiency

Correct Answer is A

Explanation

Choice A reason: Thick, white plaques suggest oral thrush, often Candida, linked to HIV immunosuppression. Facilitating HIV testing addresses a potential underlying cause, as CD4 decline allows opportunistic infections, making this the critical next step for diagnosis and management here.

Choice B reason: Referral for medication treats thrush symptomatically but misses underlying HIV risk. Antifungals help, yet without addressing immunosuppression, recurrence persists, making this less urgent than testing for a systemic condition driving the plaques in this scenario fully.

Choice C reason: Jaundice causes yellowing, not white plaques, which are fungal, not hepatic. Assessing for this misaligns with the finding’s etiology, as thrush ties to immunity, not liver function, rendering it irrelevant to the client’s oral presentation entirely here.

Choice D reason: Zinc deficiency causes taste loss or ulcers, not thick plaques like thrush. Lab review for this overlooks the infectious, possibly HIV-related cause, missing the immunological context critical to addressing the client’s specific oral condition accurately and promptly.

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The nurse is assessing cranial nerves 3, 4 and 6 (oculomotor, trochlear and abducens). Which technique might the nurse use to assess all three in one technique?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

The nurse assesses thick, white plaques on a client's tongue and hard palate. Which of the following nursing actions should the nurse do next?

Correct Answer is A

Explanation

The nurse has begun the objective assessment of a client's heart and neck vessels and is assessing the client's jugular veins. What finding would the nurse consider to be expected in a healthy client?

The nurse is reviewing a client's electronic health record before assessing her mouth. Which of the following diagnoses would the nurse recognize as an indication for immediate medical follow up?

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?

A client comes in with complaints of a headache. The client states, "I always wake up with a headache in the morning, but it gets better in a couple hours. I notice that it always gets worse if I cough or sneeze." What action by the nurse is most appropriate?

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?

A health promotion teaching is focusing on hygiene and the prevention of illness. When instructing clients on how to clean their ears, what action should the nurse recommend?

A client has a family history of prostate cancer and is committed to regular screening. What should the nurse teach the client about prostate-specific antigen (PSA) blood testing?