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 C

Explanation

A. Xiphoid process:

The xiphoid process is a small, cartilaginous extension at the inferior end of the sternum (breastbone). It does not play a role in the bifurcation of the trachea.

B. Suprasternal notch:

The suprasternal notch, also known as the fossa jugularis sternalis or jugular notch, is the visible dip in the superior part of the manubrium of the sternum between the clavicular notches. It is an important anatomical landmark for assessing the position of the trachea during emergency situations but is not the location of tracheal bifurcation.

C. Sternal angle (Angle of Louis):

The sternal angle, or Angle of Louis, is a palpable notch located at the articulation of the manubrium and the body of the sternum. It is where the second rib attaches and serves as a useful reference point for counting ribs and locating internal structures like the tracheal bifurcation.

D. Costal angle:

The costal angle is the acute angle formed by the junction of the costal margins at the xiphoid process. It is not related to the tracheal bifurcation.

A. Fifth left intercostal space at the midclavicular line B. Third left intercostal space at the midclavicular line C. Fourth left intercostal space at the sternal border D. Under the left breast at the midclavicular line

Correct Answer is A

Explanation

A. Fifth left intercostal space at the midclavicular line:

Explanation: The apical pulse, or the point of maximal impulse (PMI), is typically located at the fifth intercostal space at the midclavicular line on the chest. This is the area where the heartbeat is best heard using a stethoscope in most adults.

B. Third left intercostal space at the midclavicular line:

Explanation: This location is too high for the apical pulse. The heart's apex is generally not found at the third intercostal space; it's lower, closer to the fifth intercostal space.

C. Fourth left intercostal space at the sternal border:

Explanation: This location is not the typical site for auscultating the apical pulse. The PMI is usually heard at the midclavicular line, not at the sternal border.

D. Under the left breast at the midclavicular line:

Explanation: This position is not precise enough for auscultating the apical pulse. The specific intercostal space (fifth) and midclavicular line are crucial for accurate assessment.

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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:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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