During the assessment of a client's head and neck, the nurse observes the client's facial expressions and the face for symmetry and movement. Which cranial nerve is the nurse assessing?
VII
V
III
VI
The Correct Answer is A
A) VII: The facial nerve (cranial nerve VII) is responsible for controlling the muscles of facial expression. By assessing facial symmetry and movement, the nurse evaluates the integrity and function of this nerve, which is crucial for activities such as smiling, frowning, and raising eyebrows.
B) V: The trigeminal nerve (cranial nerve V) is primarily responsible for sensation in the face and motor functions such as chewing. While it plays a role in facial movement, it does not specifically assess facial expressions.
C) III: The oculomotor nerve (cranial nerve III) controls eye movement and pupil constriction. It does not directly influence facial expressions, so it is not the nerve being assessed in this context.
D) VI: The abducens nerve (cranial nerve VI) is responsible for lateral eye movement. It is unrelated to facial expression or symmetry and is not the focus of this assessment.
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Correct Answer is ["B","C","D","E"]
Explanation
A) Range of motion: While assessing range of motion can provide information about joint function, it is not a specific component of a peripheral vascular assessment. This assessment primarily focuses on circulation and vascular integrity rather than mobility.
B) Color: Assessing the color of the upper extremities is essential in a peripheral vascular assessment. Changes in color can indicate issues such as poor circulation, hypoxia, or vascular disease, making it a critical observation.
C) Fine motor assessment by having the client touch each finger to thumb: This assessment evaluates both coordination and dexterity, which can indicate adequate blood flow to the fingers and upper extremities. It helps to assess the functional capacity of the hands in relation to vascular health.
D) Pain assessment: Evaluating for pain in the upper extremities is important, as pain can be a sign of vascular problems, including conditions like peripheral artery disease. It provides insight into the presence of ischemia or other vascular issues.
E) Pulses intact: Assessing the pulses in the upper extremities is a key component of a peripheral vascular assessment. Palpating the radial and brachial pulses helps determine blood flow and vascular function in the arms.
Correct Answer is C
Explanation
A) Notify the healthcare provider that the client is exaggerating their pain: It is inappropriate for the nurse to assume that the client is exaggerating their pain based solely on their demeanor. Pain perception is subjective and can vary greatly among individuals, especially in conditions like sickle cell anemia.
B) Wait 30 minutes and see if the client is still requesting pain medication: Delaying pain relief can lead to unnecessary suffering. Given that the client rates their pain as a 7 out of 10, which indicates significant discomfort, it is essential to address their pain promptly rather than postponing treatment.
C) Administer the pain medication as prescribed: This is the most appropriate action. Clients with sickle cell anemia often experience severe pain crises, and effective pain management is crucial. Administering the medication as prescribed supports the client's comfort and well-being.
D) Administer half of the ordered dose of pain medication: Modifying the dosage without a provider's order is not appropriate. If the full prescribed dose is warranted based on the pain level, the nurse should administer it as indicated to ensure effective pain management.