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:
VI
V
II
III
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A slight asymmetry in breast size can be expected: This response is accurate. It acknowledges the natural variation in breast size that many women experience. It's common for one breast to be slightly larger or shaped differently than the other. It assures the client that this asymmetry is normal and not a cause for concern.
B. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about: While breastfeeding can cause temporary changes in breast size and shape, not all cases of breast asymmetry are related to breastfeeding. This statement might not cover all situations, making it less accurate.
C. A sudden uneven increase in breast size is normal in adults: This statement is not accurate. Sudden changes in breast size should always be investigated, as they can indicate underlying health issues and may not be considered normal.
D. Breasts should always be symmetric: This statement is not accurate. Perfect symmetry in breast size and shape is rare. Most women have some degree of asymmetry, which is entirely normal. It's important to reassure the client that slight differences are common and not a cause for concern.
Correct Answer is B
Explanation
A. Wheezing: Wheezing is a continuous, high-pitched whistling sound usually heard during expiration. It is often associated with narrowed airways, such as in asthma or chronic obstructive pulmonary disease (COPD). Wheezing occurs due to the turbulent airflow through narrowed bronchi or bronchioles and is not typically associated with pleuritis.
B. Friction rub: Pleuritis, or inflammation of the pleura, can cause a friction rub. This sound occurs when the inflamed pleural layers rub against each other during breathing. It's a grating or rubbing sound heard on auscultation and is a hallmark sign of pleuritis.
C. Stridor: Stridor is a high-pitched, harsh sound heard during inspiration and sometimes expiration. It is often a sign of upper airway obstruction, such as in croup or anaphylaxis. Stridor results from turbulent airflow through a partially obstructed or narrowed larynx or trachea.
D. Crackles: Crackles, also known as rales, are brief, discontinuous, popping sounds heard on inspiration. They can be fine or coarse and are often associated with conditions that cause fluid or secretions in the alveoli or small airways, such as pneumonia or heart failure. Crackles are not typically associated with pleuritis.
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