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","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.

A. The location of most breast tumors. B. More prone to Injury and calcifications than other locations in the breast C. The largest quadrant of the breast D. Where most of the suspensory ligaments attach

Correct Answer is A

Explanation

A. The location of most breast tumors: This choice is correct. The upper outer quadrant of the breast is the most common site for breast tumors. This area has a higher concentration of glandular tissue, making it more susceptible to the development of tumors. Therefore, thorough examination of this area is crucial during breast examinations.

B. More prone to Injury and calcifications than other locations in the breast: While injuries can occur in any part of the breast, the statement about calcifications is not accurate. Calcifications in breast tissue can occur in various areas and are not specific to the upper outer quadrant.

C. The largest quadrant of the breast: This statement is not accurate. The breast quadrants are not distinguished by size; they are anatomical divisions used for reference during breast examinations. Each quadrant has its significance for examination purposes, but none is considered the largest.

D. Where most of the suspensory ligaments attach: The suspensory ligaments, also known as Cooper's ligaments, provide structural support to the breast tissue. While they are essential for breast anatomy, they are not concentrated in the upper outer quadrant exclusively. These ligaments are distributed throughout the breast tissue.

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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 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 performing a breast examination on a client. The nurse understands that examining the upper outer quadrant of the breast is especially important because this part is:

Correct Answer is A

Explanation

The nurse is auscultating a client's chest for breath sounds. In which situation should the nurse expect to auscultate increased breath sounds?

The nurse is performing a breast exam on a client. The client asks the nurse why the left breast is slightly larger than the right breast. Which of the following should be the appropriate response by the nurse?

The nurse is inspecting the anterior chest of an adult client. The nurse recognizes that which of the following should be included in the assessments?

The nurse is conducting a class on Breast Self Examination (BSE). The nurse should include which of these statements that indicates the proper BSE technique.

A client diagnosed with pleuritis has been admitted to the hospital and complains of pain with breathing. Which of the following assessment findings should the nurse expect when auscultating a client with pleuritis?

The nurse is auscultating the lungs of an adult client. The nurse hears low-pitched, soft breath sounds over the posterior lower lobes and inspiration that is longer than expiration. The nurse recognizes that these breath sounds are:

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 recognizes that the following statement is true regarding the internal structures of the breast: The breast is made up of: