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 A

Explanation

Choice A reason: BPH, a benign growth, doesn’t increase prostate cancer risk; they’re distinct conditions. This reassures the client factually, addressing his fear directly with evidence, making it the most appropriate and supportive response in this context accurately.
Choice B reason: Testicular self-exams check testes, not prostate. This misdirects from BPH and prostate cancer concerns, offering irrelevant advice that fails to address the client’s specific fear about his diagnosis and its implications entirely here fully.
Choice C reason: Prostate cancer isn’t rare at 53; incidence rises with age. This false reassurance dismisses real risk, undermining trust and education, making it less appropriate than clarifying BPH’s non-link to cancer in this scenario comprehensively here.
Choice D reason: While true, prostate cancer’s slow growth doesn’t address BPH’s relation to it. This generic statement misses the client’s core fear about BPH as a risk factor, rendering it less targeted than the direct clarification fully here.

A. "I am going to place my hand on your cheek, and I want you to turn your head against resistance." B. "I’m going to place my fingers in front of your ear, and I want you to open your mouth as wide as possible." C. "I want you to move your jaw from side to side and tell me if there is any pain with the movement." D. "Push out and pull in your lower jaw and let me know if you experience popping or grating."

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.

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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

A 53 year-old client was recently diagnosed with benign prostatic hypertrophy (BPH). He is fearful and states, "My good friend just died from prostate cancer and I am concerned this will happen to me." What would be the most appropriate response by the nurse?

Correct Answer is A

Explanation

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

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?

A nurse is completing a full assessment for their client on a telemetry unit. During the eye exam, a nurse shines a light into one of the client's eyes and the pupil of the other eye constricts. What is the most appropriate description of this finding?

A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve?

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A nurse is integrating health promotion education into the assessment of a client's mouth, nose and throat. What interview question is most likely to identify a risk factor for oral cancer?

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?

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A client with a wide-based, staggering, unsteady gait walks into the clinic. The gait would be correctly described as which of the following?