When teaching students how to perform an assessment, the nurse informs the students that the reason this information needs to be accurate and complete is:

To allow for the client to focus on the illness

To allow for the client to spend more time with the nurse

To allow the nurse more time to know the client

To develop a plan with interventions that promote health

Answer and Explanation

The Correct Answer is D

A. To allow for the client to focus on the illness: Accurate and complete information is crucial for developing a proper care plan but not directly related to the client’s focus on their illness.

B. To allow for the client to spend more time with the nurse: Accurate information helps in forming a plan but does not necessarily impact the amount of time spent with the nurse.

C. To allow the nurse more time to know the client: While knowing the client is important, the primary reason for accurate information is to develop effective interventions.

D. To develop a plan with interventions that promote health: Accurate and complete assessment information is essential for developing a comprehensive care plan and interventions that address the client’s health needs.

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Correct Answer is B

Explanation

A. Ears: Evaluation of the ears is primarily concerned with hearing and balance, which involve cranial nerves such as VIII (Vestibulocochlear), not IX, X, and XII.

B. Mouth and throat: Cranial nerves IX (Glossopharyngeal), X (Vagus), and XII (Hypoglossal) are assessed through the examination of the mouth and throat. CN IX and X are evaluated by checking the gag reflex and the ability to swallow, while CN XII is assessed by examining tongue movements.

C. Head and face: The assessment of the head and face generally involves cranial nerves V (Trigeminal) and VII (Facial), which control facial sensation and movement, rather than IX, X, and XII.

D. Mental status examination: While mental status is crucial for overall health assessment, it does not specifically target cranial nerves IX, X, and XII.

A. Diverticulosis B. Nephrolithiasis C. Acute Cholecystitis D. Appendicitis

Correct Answer is C

Explanation

A. Diverticulosis: This condition involves the formation of pouches in the colon and is not associated with Murphy's sign.

B. Nephrolithiasis: This refers to kidney stones and is not associated with Murphy's sign.

C. Acute Cholecystitis: Murphy's sign is a clinical test for acute cholecystitis, which is inflammation of the gallbladder. It is positive when the patient experiences pain upon palpation of the gallbladder area during inhalation.

D. Appendicitis: Appendicitis is an inflammation of the appendix and is not related to Murphy's sign.

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When teaching students how to perform an assessment, the nurse informs the students that the reason this information needs to be accurate and complete is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing a head-to-toe assessment, during which part would the nurse evaluate cranial nerve (CN) IX, X, and XII?

Correct Answer is B

Explanation

A positive Murphy's sign is indicative of?

Correct Answer is C

Explanation

The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following?

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Use of tobacco products and excessive alcohol consumption are principal risk factors for oral carcinoma.

Cranial nerves involved in eye movements are:

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