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 C
Explanation
A. Metabolic alkalosis is characterized by a high pH and elevated bicarbonate levels, which is not present in these results.
B. Respiratory alkalosis would present with an increased pH and decreased PaCO2, which does not apply here.
C. The low pH (7.12) indicates acidemia, and the elevated PaCO2 (90 mm Hg) suggests hypoventilation and respiratory acidosis due to CO2 retention. The bicarbonate level is within normal limits, further supporting respiratory acidosis.
D. Metabolic acidosis would be indicated by a low pH and low bicarbonate levels; however, the bicarbonate is normal in this case, ruling out metabolic acidosis.
Correct Answer is A
Explanation
A. The bell of the stethoscope is best used to listen for low-pitched sounds, including some types of murmurs, and can help assess the quality and intensity of a cardiac murmur.
B. While palpation can provide some information about the heart's function (such as thrills), it is not the primary method for assessing the quality of a murmur.
C. A Doppler ultrasound device is used for measuring blood flow and can help in assessing murmurs but does not provide the quality assessment needed for characterizing a murmur.
D. Percussion is not typically used to evaluate murmurs; it is more useful for assessing the size and borders of organs.