The nurse is preparing to measure the visual acuity of a client. The nurse should recognize that which of the following cranial nerve should be assessed:

III

Answer and Explanation

The Correct Answer is C

A. VI

Cranial Nerve VI is the Abducent Nerve, which controls the movement of the lateral rectus muscle, allowing the eye to move laterally (abduct). Dysfunction of this nerve can cause difficulty in moving the eye outward.

B. V

Cranial Nerve V is the Trigeminal Nerve. It has both sensory and motor functions. Sensory functions include providing sensation to the face, sinuses, and teeth. Motor functions include controlling the muscles used for chewing (mastication).

C. II

Cranial Nerve II is the Optic Nerve. It is purely a sensory nerve responsible for vision. The optic nerve carries visual information from the retina of the eye to the brain.

D. III

Cranial Nerve III is the Oculomotor Nerve. It is primarily a motor nerve but also has some autonomic functions. It controls most of the eye movements (except lateral movement controlled by VI) and regulates the size of the pupil and the shape of the lens in the eye for focusing.

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Correct Answer is B

Explanation

A. Simultaneously palpating both arteries to compare amplitude: While comparing amplitudes is important, using the diaphragm of the stethoscope to listen for bruits (abnormal whooshing sounds indicating turbulent blood flow) is a more specific and accurate method for assessing the carotid arteries for potential vascular issues.

B. Listening with the diaphragm of the stethoscope to assess for bruits: This technique allows the nurse to detect abnormal sounds (bruits) that could indicate partial blockages or stenosis in the carotid arteries, suggesting a risk of stroke or transient ischemic attack.

C. Instructing the patient to take slow deep breaths during auscultation: Deep breaths are more relevant during lung auscultation. Carotid artery assessment focuses on detecting abnormal sounds and assessing blood flow rather than respiratory patterns.

D. Palpating the artery at the base of the neck: Palpation alone does not provide enough information about potential blockages or abnormalities in the carotid arteries. Listening with a stethoscope allows for a more detailed assessment of blood flow and the presence of bruits.f the nurse hears a bruit during auscultation, they shouldnotpalpate the carotid artery. A bruit suggests partial obstruction (carotid stenosis), and compressing the artery further could worsen blood flow.

A. Increased temperature B. Increase hematocrit C. Blood pressure 180/100 D. Respiratory rate 32 E. Heart rate 120bpm

Correct Answer is ["C","D"]

Explanation

A. Increased temperature: Fluid overload typically doesn't cause an increased temperature. Infections or other inflammatory processes are more likely causes of elevated body temperature.

B. Increased hematocrit: Fluid overload usually results in dilution of blood components, leading to a decreased hematocrit (lower concentration of red blood cells in the blood). An increased hematocrit is not a typical finding in fluid overload.

C. Blood pressure 180/100: Elevated blood pressure can be associated with fluid overload, especially if the overload is chronic. This is a correct assessment finding that requires intervention and monitoring.

D. Respiratory rate 32: An increased respiratory rate can be a sign of respiratory distress, which may occur in severe cases of fluid overload, especially if it leads to pulmonary edema. This is a correct assessment finding that requires intervention and further evaluation.

E. Heart rate 120 bpm: An increased heart rate can be a compensatory mechanism in response to fluid overload, especially if the heart is trying to maintain cardiac output. However, this heart rate alone is not specific enough to confirm fluid overload. Other signs and symptoms, such as edema, increased blood pressure, and respiratory distress, are more indicative of fluid overload.

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The nurse is preparing to measure the visual acuity of a client. The nurse should recognize that which of the following cranial nerve should be assessed:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is completing an assessment on a client suspected of having a transient ischemic attack. Which of the following techniques should the nurse use to assess the client's carotid arteries?

Correct Answer is B

Explanation

The nurse is assessing a client diagnosed with fluid overload. The nurse should implement priority interventions for which of the following assessment findings? (Select all that apply.)

Correct Answer is ["C","D"]

Explanation

The nurse is assessing the heart sounds of a client. The nurse understands that to listen to the pulmonic valve, the stethoscope should be placed where?

A nurse is reviewing the anatomy and physiologic functioning of the heart. The nurse should recognize that which statement best describes the atrial kick?

Which of the following assessment findings should the nurse report to the practitioner? (Select all that apply)

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction?

The nurse is listening to the breath sounds of young adult client with severe asthma. The nurse recognizes that air passing through narrowed bronchioles would produce which of these adventitious sounds?

The nurse is discussing the blood flow pattern of the heart. The nurse should recognize which of the following as the accurate blood flow pattern of the heart?

The nurse is examining a client for tactile fremitus. The nurse recognizes that when examining for tactile fremitus it is important to: