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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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Correct Answer is A

Explanation

A. Wheezes are continuous high-pitched sounds that occur during expiration (or sometimes inspiration) and are common in conditions like asthma due to narrowed airways.

B. Crackles are discontinuous sounds often described as popping or crackling and are not typically high-pitched.

C. Rhonchi are low-pitched, snoring-like sounds caused by the obstruction of larger airways and are not characterized as high-pitched.

D. Stridor is a high-pitched sound usually associated with upper airway obstruction and is not typically heard with asthma.

Correct Answer is ["B","C","D"]

Explanation

A. Pale yellow urine is typically associated with good hydration; dehydration would likely result in darker urine.

B. Poor skin turgor is a classic sign of dehydration, indicating a lack of adequate fluid in the tissues.

C. Hypotension (low blood pressure) can occur with dehydration due to decreased blood volume.

D. Flat neck veins may indicate a decrease in venous return due to low blood volume associated with dehydration.

E. Bradycardia (slow heart rate) is not typically a finding associated with dehydration; instead, dehydration often leads to tachycardia (increased heart rate) as the body attempts to compensate for low blood volume.

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