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 B

Explanation

A. Bowel sounds, abdominal girth, and NG tube output provide important information about gastrointestinal function and the potential for complications like ileus or obstruction. However, they do not provide direct information regarding fluid volume status.
B. Vital signs (including blood pressure and heart rate), cardiac rhythm, and peripheral pulses are the first indicators to assess for decreased fluid volume. Hypovolemia often manifests as tachycardia, hypotension, and weak peripheral pulses, which are critical early signs of fluid depletion.
C. Blood Urea Nitrogen (BUN), creatinine, and daily weight are useful in assessing kidney function and long-term fluid status, but they may not be as immediate indicators of acute fluid volume changes in the immediate postoperative period.
D. Respiratory rate, depth, and pulse oximetry are important for assessing respiratory function and oxygenation. While fluid volume imbalances can impact respiratoryfunction, these parameters are not the most direct indicators of fluid volume status.

A. large, with evidence of distant metastasis. B. in the superficial tissues of the body. C. localized to one tissue or body area. D. spread to multiple sites in one organ.

Correct Answer is C

Explanation

A. Large tumors with distant metastasis may not respond well to radiation therapy, as the effectiveness diminishes when cancer spreads beyond the primary site.
B. While radiation can be effective for superficial cancers, it is most impactful when the cancer is localized.
C. Radiation therapy is most effective for localized cancers, where the treatment can target the tumor directly without affecting surrounding healthy tissues extensively.
D. Cancer spread to multiple sites in one organ complicates treatment and may reduce the efficacy of radiation therapy, as multiple targets may require different approaches.

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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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Explanation

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