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. A pulse oximeter is used to measure oxygen saturation and is not relevant to cochlear dysfunction.
B. A hearing aid is appropriate for someone with cochlear dysfunction as it can help amplify sound and improve hearing, indicating the client is adapting to the hearing loss.
C. Eyeglasses are used for vision problems and do not relate to the function of the cochlear division of the vestibulocochlear nerve.
D. A bath thermometer is used to measure water temperature and is not relevant to auditory issues.
Correct Answer is D
Explanation
A. Providing a safe and comfortable environment and applying critical thinking involves both objective and subjective data collection, not just one type.
B. While family members can contribute to patient care, the professional responsibilities of providing a safe environment and critical thinking in assessments fall to trained healthcare providers.
C. This process encompasses both subjective and objective data, as critical thinking requires integrating multiple types of information.
D. The actions described are essential professional responsibilities of trained healthcare providers, who must ensure a safe environment, apply critical thinking, and identify patient cues effectively.