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.

Answer and Explanation

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.

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.

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Correct Answer is C

Explanation

A) At the angle of the mandible:

Lymph nodes located at the angle of the mandible are the submandibular lymph nodes, not the occipital lymph nodes. These nodes are situated below the jawline and are assessed when looking for infections or abnormalities in the oral cavity and throat.

B) Temporal area:

The temporal area is not a typical location for lymph node palpation. This region is primarily related to the temporal artery and muscles, not to lymph nodes. Thus, palpating for lymph nodes here would not be relevant.

C) The posterior base of the skull:

The occipital lymph nodes are located at the posterior base of the skull, near the nape of the neck. These nodes drain the scalp and are assessed when there are scalp infections or other related conditions.

D) Area in front of the ears:

The lymph nodes in front of the ears are the preauricular lymph nodes. These nodes drain the eyes and the surrounding skin. They are not the occipital lymph nodes, which are situated at the back of the head.

A. Encourage the client to look at the balance beam B. Have the client wear the same clothing every day. C. Weigh the client at the same time in the morning D. Use the same scale to weigh the client. E. Discuss the client's weight with her after each measurement.

Correct Answer is ["B","C","D"]

Explanation

A) Encourage the client to look at the balance beam:

Encouraging the client to look at the balance beam may help her feel more engaged in the process of weight measurement. This can foster trust and cooperation during what may be a challenging procedure due to her history of Anorexia and Bulimia Nervosa.

B) Have the client wear the same clothing every day:

Consistency in clothing helps to minimize variations in weight measurements that could be attributed to changes in clothing weight rather than actual body weight fluctuations. This practice ensures more accurate and reliable serial weight measurements.

C) Weigh the client at the same time in the morning:

Weighing the client at the same time each day helps to standardize conditions and minimize daily variations due to factors like hydration levels and food intake, providing more accurate serial weight measurements.

D) Use the same scale to weigh the client:

Using the same scale ensures consistency in measurement accuracy. Different scales can yield slightly different readings, which could affect the interpretation of weight trends over time.

E) Discuss the client's weight with her after each measurement:

While discussing weight may be part of the client's care plan, it's not necessarily a standard action during the process of conducting serial weight measurements. The focus during the actual weighing process should be on maintaining consistency and accuracy.

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The nurse read the patient's health history cranial nerve III oculomotor paralysis. Which of the following would the nurse expect?

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Naxlex Comprehensive Predictor Exams

At which location would a nurse palpate a client's occipital lymph nodes?

Correct Answer is C

Explanation

A 22-year-old female client with a history of Anorexia and Bulimia Nervosa is prescribed serial weight measurements every day. What actions will the nurse take when conducting these serial weights? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

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