While taking a history, the nurse observes that the patient's facial cranial nerves (CN VII) are intact based on which behaviors of the patient?

The sides of the mouth are symmetric when the patient smiles.

The patient's eyes move to the left, right, up, down, and obliquely during conversation.

The patient's eyelids blink periodically.

The patient moistens the lips with the tongue.

Answer and Explanation

The Correct Answer is A

Choice A rationale

The sides of the mouth being symmetric when the patient smiles indicate intact function of the facial cranial nerve (CN VII). This nerve controls the muscles responsible for facial expressions, including smiling, frowning, and closing the eyes. Symmetry in these actions suggests that the facial nerve is functioning properly and that there is no nerve damage or weakness.

Choice B rationale

The patient's eyes moving to the left, right, up, down, and obliquely during conversation are functions of the oculomotor nerve (CN III), trochlear nerve (CN IV), and abducens nerve (CN VI), not the facial cranial nerve (CN VII). These nerves work together to control the movements of the eye muscles, enabling the eyes to move in different directions and maintain proper alignment.

Choice C rationale

Periodic blinking of the eyelids involves the oculomotor nerve (CN III) and the facial nerve (CN VII). The oculomotor nerve controls the muscles that lift the eyelid, while the facial nerve controls the muscles that close the eyelid. Blinking is a coordinated action involving both nerves, but the observation alone is not sufficient to determine the integrity of CN VII.

Choice D rationale

The patient moistening the lips with the tongue involves the function of the hypoglossal nerve (CN XII), which controls the movements of the tongue. The hypoglossal nerve is responsible for the motor control of most of the tongue muscles, allowing for actions like licking the lips, speaking, and swallowing. It is not related to the facial cranial nerve (CN VII).

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Correct Answer is A

Explanation

Choice A rationale

The Romberg test evaluates equilibrium by having the client stand with feet together and eyes closed, observing for swaying or imbalance. It assesses the function of the vestibular system, proprioception, and cerebellar function, making it the most appropriate test for assessing dizziness and equilibrium.

Choice B rationale

The Weber test involves placing a tuning fork on the forehead to evaluate sound lateralization. It assesses hearing loss but not equilibrium, making it less suitable for dizziness assessment.

Choice C rationale

The Rinne test compares air and bone conduction of sound using a tuning fork. While useful for diagnosing conductive hearing loss, it does not assess equilibrium, making it inappropriate for evaluating dizziness.

Choice D rationale

The cover test evaluates eye alignment and muscle function by having the client cover one eye and observe the uncovered eye for movement. It assesses ocular motility but not equilibrium, making it unsuitable for dizziness assessment.

A. Fibrocystic lesions. B. A normal finding of the breast. C. Carcinoma of the breast. D. Fibroadenoma.

Correct Answer is C

Explanation

Choice A rationale

Fibrocystic lesions in the breast are benign changes that involve the formation of cysts and fibrous tissue. These do not typically cause an orange-peel appearance of the skin.

Choice B rationale

A normal finding of the breast would not include an orange-peel or "peau d'orange" appearance, as this is considered an abnormal change often associated with underlying pathology.

Choice C rationale

Carcinoma of the breast can lead to an orange-peel appearance of the skin due to lymphatic obstruction. This dimpling effect is caused by the cancerous infiltration and thickening of the skin, making this the correct answer.

Choice D rationale

Fibroadenoma is a benign tumor of the breast and does not usually cause the skin changes described as orange-peel appearance. This condition is generally not associated with skin texture changes.

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While taking a history, the nurse observes that the patient's facial cranial nerves (CN VII) are intact based on which behaviors of the patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client reports dizziness on her yearly physical exam.Which of the following tests would be the most appropriate to assess the client's equilibrium?

Correct Answer is A

Explanation

During the breast examination of a client, the nurse notes an orange-peel or "peau d'orange" appearance of the skin of the breast.The nurse understands that this appearance of the skin is due to what type of breast condition?

Correct Answer is C

Explanation

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