The nurse prepares to assess the patient's cranial nerves. Which tool is necessary to assess cranial nerve (CN) III (oculomotor)?

Otoscope

Penlight

Cotton ball

Lavender

Answer and Explanation

The Correct Answer is B

A. An otoscope is used to examine the ear canal and tympanic membrane, not to assess cranial nerve III. This tool is more relevant for assessing cranial nerve VIII (vestibulocochlear), which is responsible for hearing and balance.
B. A penlight is used to assess CN III (oculomotor) by evaluating the pupil's response to light and the ability to move the eye. This nerve controls most of the eye's movements, including constriction of the pupil in response to light.
C. A cotton ball is used to test the sensory function of cranial nerve V (trigeminal), which is responsible for facial sensation. It is not used for assessing CN III.
D. Lavender or other scents may be used to test CN I (olfactory), responsible for the sense of smell, but it is not related to CN III, which governs eye movements and pupil reactions.

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Correct Answer is C

Explanation

A. While being alert for non-verbal clues for pain or discomfort is important, it does not directly address the risk for ineffective airway clearance.
B. Answering for the client during rounds with the physician may compromise the client's ability to communicate their needs and concerns, which is not appropriate.
C. Assessment of the ability to cough and swallow is crucial for clients who have undergone oral surgery, as it directly relates to their airway clearance and safety in managing secretions.
D. Providing enough time for the client to respond is important for overall communication and comfort but does not specifically address the risk for ineffective airway clearance, which requires more targeted interventions.

A. stomatitis associated with laryngeal cancer. B. leukemia ordered to receive an antiemetic before scheduled chemotherapy. C. neutropenia just admitted with a possible infection. D. breast cancer scheduled for external beam radiation that morning.

Correct Answer is C

Explanation

A. While stomatitis can cause discomfort and complications, it is not an immediate threat compared to infection risk.
B. The client with leukemia may require monitoring, but the antiemetic is pre-emptive and not immediately critical.
C. The client with neutropenia and a possible infection poses the highest risk, as they are vulnerable to severe complications due to their compromised immune system. Immediate assessment is necessary to manage and treat potential infections promptly.
D. The breast cancer client scheduled for radiation requires care but is not in an urgent condition compared to the neutropenic patient.

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The nurse prepares to assess the patient's cranial nerves. Which tool is necessary to assess cranial nerve (CN) III (oculomotor)?

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Naxlex Comprehensive Predictor Exams

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