The nurse read the patient's health history cranial nerve III oculomotor paralysis. Which of the following would the nurse expect?
Муоріа
Normal eye movement
Ptosis will be evident and no pupillary constriction.
The eye cannot look to the outside side.
The Correct Answer is C
(a) Mydriasis:
While mydriasis (dilated pupil) can be associated with cranial nerve III damage, it does not fully describe the range of symptoms expected with oculomotor paralysis. Cranial nerve III controls more functions than pupil dilation, such as eyelid elevation and certain eye movements.
(b) Normal eye movement:
Cranial nerve III paralysis would result in abnormal eye movement due to the loss of control over muscles responsible for moving the eye. Expecting normal eye movement would be incorrect since the paralysis affects the eye's ability to move properly.
(c) Ptosis will be evident and no pupillary constriction:
Cranial nerve III (oculomotor nerve) paralysis leads to ptosis (drooping eyelid) because it innervates the levator palpebrae superioris muscle. It also affects the pupillary constrictor muscles, resulting in a dilated pupil (lack of pupillary constriction), making this the most comprehensive and accurate answer.
(d) The eye cannot look to the outside side:
Inability to look to the outside (lateral movement) is typically associated with cranial nerve VI (abducens nerve) paralysis, which controls the lateral rectus muscle. Cranial nerve III primarily affects vertical and medial movements, so this is not the expected finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Size:
When assessing lymph nodes, noting the size is crucial as enlarged lymph nodes can indicate infection, inflammation, or malignancy. Size helps in determining the extent and severity of the underlying condition.
B) Consistency:
The consistency of lymph nodes (whether they are hard, rubbery, or soft) provides important diagnostic information. For instance, hard lymph nodes may suggest malignancy, while soft nodes might indicate an infection.
C) Shape:
Recording the shape of lymph nodes is essential in the assessment process. Regular, oval, or round shapes can be normal, while irregularly shaped nodes might be concerning and warrant further investigation.
D) Color:
Color is not typically assessed or noted when examining lymph nodes. Lymph nodes are internal structures, and their color cannot be directly observed without invasive procedures. The focus is usually on palpable characteristics like size, consistency, and shape.
Correct Answer is A
Explanation
A. 20 represents the distance you are placed from the chart and 40 represents the distance a normal eye reads the chart:
This is correct. The first number (20) represents the distance in feet the patient is from the Snellen chart. The second number (40) indicates the distance at which a person with normal vision can read the same line. Therefore, 20/40 means that what the patient can read at 20 feet, a person with normal vision can read at 40 feet.
B. 20 represents the distance a normal eye can read and 40 represents the distance your eye reads the chart:
This is incorrect. The first number should represent the distance the patient is from the chart, not the normal eye's reading distance.
C. 20 represents the distance you are placed from the chart and 40 represents the distance your eye reads the chart:
This is incorrect. While the first number is correct (the distance from the chart), the second number should represent the distance a person with normal vision can read the same line, not the patient's distance.
D. 40 represents the distance you are placed from the chart and 20 represents the distance a normal eye reads the chart:
This is incorrect. The standard for visual acuity measurements is that the first number represents the testing distance (usually 20 feet), and the second number represents the distance at which a normal eye can read the line.
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