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 C
Explanation
(a) Inquire about family history of headaches:
While understanding the client's family history of headaches can be important for a comprehensive assessment, it is not the immediate priority. The description of "the worst headache" ever experienced could indicate a serious condition that needs urgent attention.
(b) Review the client's medical record:
Reviewing the client's medical record provides valuable information about their history and potential underlying conditions. However, given the severity of the reported headache, it is crucial to perform a more immediate physical assessment to rule out life-threatening conditions.
(c) Assess the client's blood pressure:
Assessing the client's blood pressure is a critical initial action. A severe headache can be a symptom of hypertensive crisis, stroke, or other serious conditions. High blood pressure could provide an immediate clue to the severity and cause of the headache, allowing for quicker intervention.
(d) Provide medication for pain relief:
Providing pain relief is important, but it should not be the first action without determining the cause of the headache. Administering medication without assessing the client's condition could mask symptoms of a potentially serious underlying issue such as a stroke or hypertensive emergency.
Correct Answer is A
Explanation
A) Presbyopia: Presbyopia is an age-related condition where the lens of the eye loses elasticity, making it harder to focus on close objects. This condition typically begins to affect individuals around the age of 40, causing them to hold reading materials farther away to see them clearly. The client's complaint aligns perfectly with this common symptom of presbyopia.
B) Cataracts: Cataracts involve the clouding of the eye's lens, leading to overall blurry vision, glare, and difficulty with night vision. Although cataracts can interfere with reading, they do not specifically cause the need to hold reading materials farther away, which is more indicative of presbyopia.
C) Tropia: Tropia is a type of strabismus where one eye deviates from normal alignment, leading to symptoms like double vision or eye strain. This condition affects how the eyes coordinate but does not typically cause the specific symptom of needing to hold reading materials farther away.
D) Myopia: Myopia, or nearsightedness, results in clear vision for close objects but blurry vision for distant objects. The client's issue of needing to hold reading materials farther away to see clearly is inconsistent with myopia, which would cause difficulty with distant vision instead.
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