A nurse is precepting a nursing student. The nurse explains to the nursing student how you would perform the graphesthesia test on a client. What is the correct way to perform this test?
The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred.
The nurse will briefly touch the client, and the client will need to identify where the touch occurred.
Client will close their eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object.
The client is to identify the numbers of points felt when the nurse touches the client with the ends of two applicators at the same time.
The Correct Answer is C
A. This description relates more to a sensory discrimination test, not graphesthesia.
B. This option does not accurately describe the graphesthesia test, which involves identifying shapes or numbers rather than just touch location.
C. In the graphesthesia test, the client closes their eyes while the nurse uses a blunt object to write a number or shape in the client's palm, and the client must identify what was written. This assesses the ability to recognize letters or numbers drawn on the skin.
D. This option describes a two-point discrimination test rather than graphesthesia, which focuses on identifying drawn shapes or numbers.
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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 A
Explanation
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.