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 D
Explanation
A. Presbyopia refers to age-related difficulty in seeing close objects due to loss of elasticity in the lens, not distance vision.
B. Astigmatism is a condition caused by an irregular curvature of the eye, leading to blurred vision at any distance.
C. Hyperopia (farsightedness) is the inability to see close objects clearly, not distant ones.
D. Myopia (nearsightedness) is the condition where a person cannot see objects at a distance clearly, making it the correct term for this finding.
Correct Answer is ["B","C","E"]
Explanation
A. The diaphragm of the stethoscope is used for high-pitched sounds, such as lung and normal heart sounds, not low-pitched sounds.
B. The binaural (earpieces) should fit snugly in the ears to ensure proper sound transmission and clarity.
C. Short tubing provides more accurate sounds by minimizing sound distortion, making it ideal for clinical use.
D. The bell of the stethoscope is used for low-pitched sounds, such as heart murmurs, not high-pitched sounds.
E. The stethoscope works by blocking out environmental sounds to help the user focus on internal body sounds.