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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. Flexion refers to bending the joint, which does not apply when turning the palm down.

B. Supination is the movement of turning the palm up, which is the opposite of what is being tested here.

C. Rotation refers to the circular movement around a central point, but it does not specifically describe the action of turning the palm down.

D. Pronation is the movement of turning the palm down, which is exactly what the client is doing when asked to perform this maneuver.

Correct Answer is D

Explanation

A. Generalized joint discomfort is not commonly associated with contact dermatitis; this condition typically affects the skin locally rather than causing systemic joint symptoms.

B. Systemic symptoms such as elevated temperature are generally not expected with contact dermatitis, as it is usually a localized skin reaction.

C. Pruritus (itching) is a common symptom of contact dermatitis, so denial of pruritus would not be expected.

D. Contact dermatitis often occurs due to exposure to a skin irritant, making a report of such exposure a typical finding in the assessment.

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