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A nurse is assessing a client's cranial nerves as part of a neurological examination. Which action should the nurse take to assess cranial nerve II?

A.

Assess visual acuity

B.

Elicit gag reflex

C.

Checking for pupillary response to light

D.

Observing for facial symmetry

Answer and Explanation

The Correct Answer is A

A. Assessing visual acuity directly tests cranial nerve II (the optic nerve), which is responsible for vision.  

 

B. Eliciting the gag reflex tests cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve II.  

 

C. Checking for pupillary response to light primarily assesses the function of cranial nerve II but is more associated with cranial nerve III (oculomotor) since it involves the constriction of the pupil. While relevant, it is not the best standalone action for assessing cranial nerve II specifically.  

 

D. Observing for facial symmetry is associated with cranial nerve VII (facial nerve), not cranial nerve II.


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View Related questions

Correct Answer is D

Explanation

A. The tympanic temperature of 37.1° C (98.8° F) is within normal limits and does not require re-measurement.

B. The respiratory rate of 14/min is also within the normal range (12-20 breaths per minute).

C. The blood pressure of 98/77 mm Hg is not alarmingly low and does not require immediate re-measurement.

D. A pulse rate of 42/min indicates bradycardia (normal resting heart rate is typically between

Correct Answer is A

Explanation

A. Asking the client to identify scented aromas assesses cranial nerve I (olfactory nerve), which is responsible for the sense of smell.


B. Reading a Snellen chart assesses cranial nerve II (optic nerve), which is related to vision.


C. Listening to the client's speech evaluates the function of cranial nerves V (trigeminal) and XII (hypoglossal), which are related to mastication and tongue movement, respectively.


D. Asking the client to clench his teeth tests cranial nerve V, which innervates the muscles of mastication.

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