Nokea
The nurse is assessing the client's cranial nerves. Which assessment data indicate cranial nerve I is intact?
- A. The client can identify cold and hot on the face.
- B. The client does not have any tongue tremor.
- C. The client has no ptosis of the eyelids.
- D. The client is able to identify a peppermint smell.
Correct Answer: D
Rationale: Cranial nerve I (olfactory) is assessed by identifying smells like peppermint. Temperature sensation (trigeminal), tongue movement (hypoglossal), and ptosis (oculomotor) involve other nerves.
You may also like to solve these questions
The client is scheduled for right-eye cataract removal surgery in five (5) days. Which preoperative instruction should be discussed with the client?
- A. Administer dilating drops to both eyes for 72 hours prior to surgery.
- B. Prior to surgery do not lift or push any objects heavier than 15 pounds.
- C. Make arrangements for being in the hospital for at least three (3) days.
- D. Avoid taking any type of medication which may cause bleeding, such as aspirin.
Correct Answer: D
Rationale: Avoiding bleeding-risk medications like aspirin prevents intraoperative hemorrhage. Dilating drops are not used for 72 hours, lifting restrictions are postoperative, and cataract surgery is typically outpatient.
A client has had a cataract extraction performed. Which statement would indicate that the client needs more teaching?
- A. I will take a stool softener daily.'
- B. I'm going to start doing calisthenic exercises as soon as I get home.'
- C. I'm going to my daughter's for a few weeks until I am recovered.'
- D. I am looking forward to watching television during my recovery period.'
Correct Answer: B
Rationale: Calisthenic exercises involving bending or lifting should be avoided post-cataract extraction to prevent increased intraocular pressure.
Which risk factors should the nurse discuss with the client concerning reasons for hearing loss? Select all that apply.
- A. Perforation of the tympanic membrane.
- B. Chronic exposure to loud noises.
- C. Recurrent ear infections.
- D. Use of nephrotoxic medications.
- E. Multiple piercings in the auricle.
Correct Answer: A,B,C,D
Rationale: Tympanic perforation, loud noise, ear infections, and ototoxic medications (e.g., aminoglycosides) cause hearing loss. Auricle piercings are cosmetic and unrelated.
The client's daughter tells the nurse of frustration while communicating with her elderly mother who wears hearing aids. Which intervention should the nurse suggest to the client's daughter?
- A. Minimize oral communication to essential matters.
- B. Speak directly into her mother's better ear.
- C. Use exaggerated mouth expressions while speaking.
- D. Attract her mother's attention before speaking.
Correct Answer: D
Rationale: Attracting the client's attention improves communication by including the client fully from the start. Minimizing communication, speaking into the ear, or exaggerated expressions are less effective.
The client with glaucoma is prescribed pilocarpine hydrochloride 1% eye drops to both eyes four times per day. The nurse knows that this medication has which expected action?
- A. Increases the outflow of aqueous humor
- B. Improves vision in dimly lit environments
- C. Increases production of aqueous humor
- D. Increases ability of both pupils to dilate
Correct Answer: A
Rationale: Pilocarpine hydrochloride is a cholinergic agent used to treat glaucoma. It causes miosis (pupillary constriction), which then increases the angle of the channel in the anterior chamber of the eye. This improves the outflow of aqueous humor. It does not improve vision in dim light, increase aqueous humor production, or cause pupil dilation.