The nurse read the patient's health history and noted cranial nerve III oculomotor paralysis. Which of the following would the nurse expect?
The eye cannot look to the outside.
Myopia.
Ptosis will be evident and no pupillary constriction.
Normal eye movement.
The Correct Answer is C
Choice a reason:
The inability of the eye to look outward, known as lateral rectus palsy, is associated with cranial nerve VI, the abducens nerve, not the oculomotor nerve. The oculomotor nerve does not control the lateral rectus muscle which governs this movement.
Choice b reason:
Myopia, or nearsightedness, is a refractive error of the eye where distant objects appear blurry while close objects can be seen clearly. It is not related to oculomotor nerve paralysis, which affects eye movements and pupil response, not the shape of the eyeball or the refractive properties of the lens.
Choice c reason:
Ptosis, or drooping of the upper eyelid, and an absence of pupillary constriction are classic signs of oculomotor nerve paralysis. The oculomotor nerve controls most of the eye's movements, including lifting the eyelid via the levator palpebrae superioris muscle and constricting the pupil through the circular muscles of the iris.
Choice d reason:
Normal eye movement would not be expected in a patient with oculomotor nerve paralysis. This nerve controls the majority of the eye's movements, so paralysis would lead to abnormal eye movement, such as the inability to move the eye upward, downward, or inward.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Palpitations are typically associated with hyperthyroidism, not hypothyroidism. They occur due to an excess of thyroid hormones, which can overstimulate the heart, leading to increased heart rate and palpitations. In hypothyroidism, the heart rate is usually slower, and palpitations are less common.
Choice B Reason:
Diaphoresis, or excessive sweating, is also more commonly associated with hyperthyroidism. In hypothyroidism, the metabolism is slowed down, which reduces the tendency for increased sweating. Patients with hypothyroidism may actually have less sweating than normal.
Choice C Reason:
Weight gain is a common symptom of hypothyroidism. Due to the decreased metabolic rate caused by low levels of thyroid hormones, the body burns fewer calories, which can lead to weight gain. This is one of the hallmark signs of hypothyroidism and is often one of the first symptoms patients notice.
Choice D Reason:
Exophthalmos, the protrusion of the eyes, is a symptom associated with Graves' disease, a form of hyperthyroidism. It is not a symptom of hypothyroidism. In hypothyroidism, any eye changes are usually related to puffiness or edema around the eyes, not the bulging of the eyes themselves.
Correct Answer is A
Explanation
Choice a reason :
Referring the client for medical follow-up is the most appropriate action. Acanthosis Nigricans is often associated with insulin resistance and is a risk factor for diabetes mellitus. The client's symptoms of fatigue, thirst, and frequent urination are classic signs of diabetes. Therefore, a comprehensive medical evaluation is necessary to rule out diabetes or other underlying conditions that could be causing these symptoms.
Choice b reason
While Acanthosis Nigricans can sometimes be associated with malignancy, it is more commonly linked to insulin resistance and diabetes. The client's presenting symptoms are not typical of cancer but are indicative of diabetes. Therefore, while a family history of cancer is relevant to the client's overall health, it is not the immediate concern based on the current presentation.
Choice c reason
Documenting findings is an essential part of the nursing process; however, the presence of Acanthosis Nigricans, especially when coupled with symptoms of fatigue, thirst, and frequent urination, should not be considered benign without further investigation. These findings warrant further assessment to determine the underlying cause.
Choice d reason
Performing a random blood sugar test could be a part of the initial assessment; however, it should not replace a referral for a comprehensive medical evaluation. A random blood sugar test alone may not be sufficient to diagnose diabetes or determine the cause of the client's symptoms. A full medical follow-up will likely include blood sugar testing along with other diagnostic tests.
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