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?
Assess visual acuity
Elicit gag reflex
Checking for pupillary response to light
Observing for facial symmetry
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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Correct Answer is B
Explanation
A. Early ventricular repolarization is represented by the T wave, not the P wave.
B. The P wave represents atrial depolarization, which is the electrical activity that triggers the contraction of the atria.
C. Slow repolarization of ventricular Purkinje fibers is represented by the T wave, not the P wave.
D. Ventricular depolarization is represented by the QRS complex, not the P wave.
Correct Answer is C
Explanation
A. Metabolic alkalosis is characterized by a high pH and a high HCO3- level; this does not match the provided values.
B. Metabolic acidosis would show a low pH and a low HCO3-, which does not match the findings.
C. The pH is high (7.45) while the Paco2 is low (30 mm Hg), indicating respiratory alkalosis. The low HCO3- could be a compensatory mechanism but does not change the primary interpretation of respiratory alkalosis.
D. Respiratory acidosis would be indicated by a low pH and a high Paco2, which is not the case here.