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The neurologist tests the 4th and 6th cranial nerves together by having a patient do which of the following?
- A. Turn his head to the right and left
- B. Say "ahhh"
- C. Identify whispering in his ears
- D. Follow his finger with his eyes
Correct Answer: D
Rationale: The neurologist tests the 4th and 6th cranial nerves together by having a patient follow his finger with his eyes. The 4th cranial nerve (trochlear nerve) innervates the superior oblique muscle, which primarily moves the eye downward and outward. The 6th cranial nerve (abducens nerve) innervates the lateral rectus muscle, which primarily moves the eye laterally. Testing these cranial nerves simultaneously by asking the patient to follow the neurologist's finger helps assess the coordination and function of both of these nerves, which are important for eye movement control.
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Which assessment action will help the nurse determine if the patient with Bell's Palsy is receiving adequate nutrition?
- A. Monitor meal trays
- B. Check twice-weekly weights
- C. Measure intake and output
- D. Assess swallowing reflex
Correct Answer: D
Rationale: By assessing the patient's swallowing reflex, the nurse can determine if the patient is able to swallow food and liquids properly, which is crucial for adequate nutrition intake. Bell's Palsy can affect facial muscles, including those involved in chewing and swallowing. A impaired swallowing reflex can lead to difficulties in eating and drinking, which in turn may affect the patient's nutrition status. Monitoring meal trays (A) may not provide direct information about the patient's ability to swallow, as a patient may not be able to communicate swallowing difficulties. Checking twice-weekly weights (B) may indicate weight changes, but it may not necessarily give insight into nutrition adequacy related to swallowing ability. Measuring intake and output (C) may help track calorie intake and fluid balance, but it may not specifically address swallowing issues that can impact nutrition in a patient with Bell's Palsy. Assessing the swallowing reflex (D) directly addresses the patient's ability to consume food and
The nurse is providing breast cancer education at a community facility. The American Cancer Society recommends that women get with mammograms:
- A. Yearly after age 40
- B. After the birth of the first child and every 2 years thereafter
- C. After the first menstrual period and annually thereafter
- D. Every 3 years between ages 20 and 40 and annually thereafter
Correct Answer: A
Rationale: The American Cancer Society recommends that women get yearly mammograms starting at age 40. This is because regular mammograms are the best way to detect breast cancer early when it's most treatable. Women at an average risk of breast cancer are advised to undergo yearly mammograms starting at age 40. Early detection through regular screening can help improve the chances of successful treatment and increase survival rates. It's important to follow these guidelines to ensure early detection and timely treatment of breast cancer.
An adult is on a clear liquid diet. Which food item can be offered/
- A. Milk
- B. Orange juice
- C. Jello
- D. Ice cream
Correct Answer: C
Rationale: When an adult is on a clear liquid diet, foods that are easy to digest and leave little residue in the gastrointestinal tract are recommended. Clear liquids include water, broth, fruit juices without pulp, and gelatin desserts like Jello. Jello is a good option because it is easily digestible, does not leave residue, and provides some calories and hydration. Milk, orange juice, and ice cream should be avoided on a clear liquid diet as they are not considered clear liquids and may not be as easily digestible.
When doing the first assessment of a male newborn, the nurse notes that the scrotum is large, edematous, and pendulous. This should be interpreted as a(n):
- A. normal finding.
- B. hydrocele.
- C. absence of testes.
- D. inguinal hernia.
Correct Answer: B
Rationale: A hydrocele presents as a fluid-filled sac surrounding the testes within the scrotum. In newborns, it is a common finding due to the open connection between the peritoneal cavity and the scrotum that may allow fluid to accumulate. This can result in a large, edematous, and pendulous scrotum. Hydroceles are usually benign and tend to resolve on their own within the first year of life. In contrast, the absence of testes (cryptorchidism) would be identified as the inability to palpate the testes in the scrotum or inguinal canal. An inguinal hernia would present as a bulge in the inguinal area caused by a loop of intestine protruding through a weak spot in the abdominal wall.
The LEAST important advice for a 2-month-old baby with excessive crying is
- A. master the situation in relaxed manner
- B. adhere to precry cues
- C. change milk formula
- D. avoid sensory overstimulation
Correct Answer: C
Rationale: Changing formula may not address refusal due to developmental factors.