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A nurse is collecting data as part of a neurological examination of a client who is receiving treatment for head trauma. Which of the following observations will give the nurse information about the function of the third cranial nerve?
- A. Instruct the client to look up and down without moving his head.
- B. Observe the client's ability to smile and frown.
- C. Evaluate the client's pupillary reaction to light.
- D. Ask the client to shrug his shoulders against passive resistance.
Correct Answer: C
Rationale: The correct answer is C: Evaluate the client's pupillary reaction to light. The third cranial nerve, also known as the oculomotor nerve, controls the pupillary response by constricting the pupil when exposed to light. By observing the client's pupillary reaction to light, the nurse can assess the function of the third cranial nerve. This test specifically targets the parasympathetic fibers of the nerve, which control pupillary constriction.
Choice A (Instruct the client to look up and down without moving his head) would assess the function of the fourth cranial nerve (trochlear nerve).
Choice B (Observe the client's ability to smile and frown) would assess the function of the seventh cranial nerve (facial nerve).
Choice D (Ask the client to shrug his shoulders against passive resistance) would assess the function of the eleventh cranial nerve (accessory nerve).
Therefore, choices A, B, and D are
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A nurse is caring for a client who is postoperative. When helping to manage the client's pain, which of the following principles should the nurse apply? (Select all that apply.)
- A. Administer opioids with caution because they will eventually lead to addiction.
- B. Consider the client's individual expression of pain.
- C. To achieve fast-acting pain relief, administer analgesics PO.
- D. Use a scale from 0 to 10 to monitor the severity of the client's pain.
- E. Expect the client to express his pain both verbally and nonverbally.
Correct Answer: B,D,E
Rationale: The correct principles to apply in managing a postoperative client's pain are B, D, and E. B is correct because pain is subjective and varies among individuals, so considering the client's individual expression of pain is crucial. D is correct because using a pain scale helps to monitor and assess the severity of the client's pain objectively. E is correct because clients may express pain in different ways, both verbally and nonverbally. These principles help tailor pain management strategies to the client's needs. Choices A and C are incorrect because opioids are necessary for acute pain management postoperatively and administering analgesics PO may not always provide fast-acting relief. Choice F and G are not provided.
A nurse is collecting data about a client's cranial nerves. Which of the following methods should the nurse use to identify a problem with cranial nerve II?
- A. Use a Snellen chart.
- B. Determine if the client's speech is hoarse.
- C. Present the client with mildly scented aromas.
- D. Ask the client to clench teeth.
Correct Answer: A
Rationale: The correct answer is A: Use a Snellen chart. Cranial nerve II, the optic nerve, is responsible for vision. By using a Snellen chart, the nurse can assess the client's visual acuity, which directly relates to the function of cranial nerve II. This method specifically targets the nerve in question and provides objective data on the client's vision.
Incorrect choices:
B: Determining if the client's speech is hoarse would assess cranial nerve X, the vagus nerve, responsible for speech and swallowing.
C: Presenting the client with scented aromas would assess cranial nerve I, the olfactory nerve, responsible for smell.
D: Asking the client to clench teeth would assess cranial nerve V, the trigeminal nerve, responsible for facial sensation and jaw movement.
A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client's temperature. Which of the following findings should the nurse identify as an indication that the client is dehydrated?
- A. Urine specific gravity 1.034
- B. Bounding pulse
- C. BP 146/94 mm Hg
- D. Distended neck veins
Correct Answer: A
Rationale: The correct answer is A: Urine specific gravity 1.034. Urine specific gravity measures the concentration of solutes in the urine, and a value of 1.034 indicates highly concentrated urine, which is a sign of dehydration. When the body is dehydrated, the kidneys conserve water, leading to concentrated urine.
Choice B, a bounding pulse, is a sign of fluid volume overload rather than dehydration. Choice C, high blood pressure, is not a direct indicator of dehydration. Choice D, distended neck veins, may be seen in conditions like heart failure but are not specific to dehydration. Overall, urine specific gravity is the most direct and reliable indicator of dehydration in this scenario.
A nurse is preparing to measure a client's oxygen saturation and notes edema of the client's hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?
- A. Finger
- B. Earlobe
- C. Toe
- D. Skin fold
Correct Answer: B
Rationale: The correct answer is B: Earlobe. The nurse should apply the pulse oximeter probe to the earlobe in this scenario because the client's hands have edema, making finger placement less reliable for accurate readings. Thickened toenails also suggest poor circulation in the toes, making toe placement less accurate. The earlobe provides a good peripheral site for accurate oxygen saturation measurement, as it has good blood flow and is less affected by edema or circulation issues. Placing the probe on the skin fold may lead to erroneous readings due to variations in skin thickness and perfusion. Therefore, the earlobe is the most suitable and reliable location for obtaining an accurate oxygen saturation measurement in this situation.
A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?
- A. Lower the height of the solution container.
- B. Encourage the client to bear down.
- C. Allow the client to expel some fluid before continuing.
- D. Stop the enema and document that the client did not tolerate the procedure.
Correct Answer: A
Rationale: Correct Answer: A: Lower the height of the solution container.
Rationale: Lowering the height of the solution container will decrease the rate of flow, reducing the pressure and volume of the solution entering the client's colon. This can help alleviate the cramping sensation by slowing down the administration of the enema.
Summary of other choices:
B: Encouraging the client to bear down may increase intra-abdominal pressure, worsening the cramping sensation.
C: Allowing the client to expel some fluid before continuing may not address the root cause of the discomfort, which is the rapid influx of solution.
D: Stopping the enema and documenting that the client did not tolerate the procedure does not actively address the client's discomfort or provide immediate relief.