Nokea
Which assessment technique should the nurse use to assess the client's optic nerve?
- A. Have the client identify different smells.
- B. Have the client discriminate between sugar and salt.
- C. Have the client read the Snellen chart.
- D. Have the client say 'ah' to assess the rise of the uvula.
Correct Answer: C
Rationale: The optic nerve (cranial nerve II) is assessed by visual acuity tests like the Snellen chart. Smells (olfactory), taste (facial/glossopharyngeal), and uvula movement (vagus) involve other nerves.
You may also like to solve these questions
A cataract extraction is performed on a client's right eye. What is the priority nursing care immediately postoperative?
- A. Assist her to turn, cough, and deep breathe every two hours.
- B. Keep her NPO for four hours.
- C. Assist her in moving her arms and legs in ROM.
- D. Position client on her right side.
Correct Answer: C
Rationale: Assisting with range of motion prevents complications like stiffness while avoiding strain on the surgical eye.
An adult man fell off a ladder and hit his head. His wife rushed to help him and found him unconscious. After regaining consciousness several minutes later, he was drowsy and had trouble staying awake. He is admitted to the hospital for evaluation. When the nurse enters the room, he is sleeping. While caring for the client, the nurse finds that his systolic blood pressure has increased, his pulse has decreased, and his temperature is slightly elevated. What does this suggest?
- A. Increased cerebral blood flow
- B. Respiratory depression
- C. Increased intracranial pressure
- D. Hyperoxygenation of the cerebrum
Correct Answer: C
Rationale: Increased systolic blood pressure, decreased pulse, and elevated temperature suggest increased intracranial pressure (Cushing's triad) post-head injury.
The client is receiving treatment with gentamicin ophthalmic solution for bacterial conjunctivitis. Which symptom, described by the client, indicates that the medication is ineffective?
- A. Eyes feel strained
- B. Yellowish eye drainage
- C. Twitching of the eye
- D. Unable to read small print
Correct Answer: B
Rationale: Mucopurulent eye drainage, especially yellowish or greenish, is associated with bacterial conjunctivitis; continuing with eye drainage indicates gentamicin is ineffective in treating the infection. Eyestrain, twitching, and inability to read small print are not associated with an infectious process.
A client asks the nurse what causes Parkinson's disease. The nurse's correct reply would be that Parkinson's disease is thought to be due to:
- A. a deficiency of dopamine in the brain.
- B. a demyelinating process affecting the central nervous system.
- C. atrophy of the basal ganglia.
- D. insufficient uptake of acetylcholine in the body.
Correct Answer: A
Rationale: Parkinson's disease is caused by a deficiency of dopamine in the brain, leading to motor symptoms.
The nurse is teaching the client who has otitis media. To reduce the risk of recurrent otitis media, which vaccine should the nurse recommend?
- A. Varicella vaccine
- B. Pneumococcal vaccine
- C. Typhoid vaccine
- D. Zoster vaccine
Correct Answer: B
Rationale: Pneumococcal vaccine can reduce the risk of ear infections. Varicella, typhoid, and zoster vaccines prevent other conditions.