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 A
Explanation
A) Report the abuse according to facility policy: The nurse has a legal and ethical responsibility to report suspected or disclosed abuse or neglect immediately, following the facility's protocols and state laws. This ensures that appropriate action is taken to protect the vulnerable individual and provides necessary interventions.
B) Consider a referral to social services: While this may be part of the broader care plan, the immediate priority is to report the abuse. Social services can be involved after the initial reporting to ensure that the appropriate support systems are put in place for the individual.
C) Meet with the patient's family: Meeting with the family may be relevant in some cases, but it is not the nurse's primary responsibility upon disclosure of abuse. Involving family members can sometimes complicate situations, especially if they are involved in the abuse.
D) Contact the primary care provider: While informing the primary care provider may be necessary as part of ongoing care, the urgent responsibility is to report the abuse to the proper authorities. The healthcare provider can then be informed as part of the care coordination after the initial report is made.
Correct Answer is A
Explanation
A) Idiopathic neuropathy has no known cause: This statement is accurate, as idiopathic neuropathy refers to nerve damage for which no specific cause can be identified despite thorough investigation. The term "idiopathic" literally means "of unknown origin," indicating that the underlying mechanism remains unclear.
B) Idiopathic neuropathy is hereditary in nature: While some neuropathies can be hereditary, idiopathic neuropathy itself is not classified as hereditary since it lacks a defined genetic cause. Hereditary neuropathies are specific types that have a genetic basis.
C) Idiopathic neuropathy is caused by nutritional deficits: Nutritional deficits can lead to various types of neuropathy, but idiopathic neuropathy specifically is characterized by the absence of a known cause. Therefore, attributing it to nutritional deficits would be incorrect.
D) Idiopathic neuropathy is caused by disease or illness: While certain diseases can cause neuropathy, the key characteristic of idiopathic neuropathy is that no specific disease or illness has been identified as the cause. This differentiates it from other neuropathies that are secondary to identifiable conditions.