The nurse is assessing the 6 stages of cardinal gaze. This test assesses:
Cranial nerves III, IV, and X for eye muscle strength.
Cranial nerves III, IV, and VI for ocular motor movements.
Cranial nerves IV, V and VII for visual accuracy.
Cranial nerve II for visual acuity.
The Correct Answer is B
The nurse is assessing the 6 stages of the cardinal gaze to evaluate the function of the cranial nerves III, IV, and VI for ocular motor movements, which control eye movement and positioning.
Cranial nerve III controls the superior rectus, inferior rectus, and medial rectus muscles, which move the eye up, down, and inward, respectively. Cranial nerve IV controls the superior oblique muscle, which moves the eye downward and laterally. Cranial nerve VI controls the lateral rectus muscle, which moves the eye outward.
Therefore, the nurse will observe the patient's ability to move their eyes smoothly in each of the six cardinal positions of gaze and note any abnormalities that may indicate dysfunction of these cranial nerves. This test is used to diagnose conditions such as strabismus, nystagmus, and palsy of the ocular motor nerves.
Cranial nerve II, on the other hand, is responsible for visual acuity, not eye movement, and is tested separately using a visual acuity chart or other vision tests.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Standard precautions refer to the basic infection prevention measures that should be taken with all patients, regardless of their known or suspected infection status. This includes hand hygiene, the use of personal protective equipment (such as gloves), and the proper handling and disposal of contaminated items.
If there is a concern for an infection, additional precautions may be necessary based on the suspected or confirmed pathogen. In such cases, the nurse should follow transmission-based precautions, which are specific measures designed to prevent the spread of certain types of infections. For example, if there is a concern for a respiratory infection such as influenza, the nurse may need to use droplet precautions, which would include wearing a mask in addition to standard precautions.
It's important for the nurse to assess the patient's medical history and current condition to determine what precautions are necessary. The nurse should also be aware of and follow the infection control policies and procedures of their healthcare facility.
Correct Answer is ["A","B"]
Explanation
When checking for edema in the lower extremities of a patient with Congestive heart failure, the nurse will grade the edema on a scale of +1 to +4 and press the skin over the tibia. Plantar flexing the feet is not necessary for assessing edema in the lower extremities, and checking only one limb is not sufficient as edema may occur in both legs.
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