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The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function will yield the best information about these cranial nerves?

A nurse in an emergency department is caring for a client who has abdominal pain.

Nurses' Notes 

0800: Client reports abdominal pain that began the previous evening. Client is two weeks postoperative from a right knee replacement. Reports taking 3 to 4 hydrocodone tablets daily for postoperative pain. Has not had bowel movement in 4 days. Reports not drinking many fluids to avoid having "to get up and go to the bathroom so often because it hurts to walk."

0830: Client taken for abdominal x-ray. Partner reports that client has not been following physical therapist's exercise regimen of walking several times daily.

0915: Fecal mass of hard, dry stool removed digitally from client per provider's order.

1015: Provided teaching to client and partner about constipation and methods to avoid further impaction.

Diagnostic Results

0900:

Abdominal x-ray: Large amount of fecal material throughout the colon with rectal impaction. No evidence of small bowel obstruction.

A nurse is providing teaching to a client who has constipation. Which information should the nurse include? (Select all that apply.)

To assess the tympanic membrane mobility, which instrument is most appropriate for the nurse to use?

The nurse is teaching a group of unlicensed assistive personnel about the stethoscope. Which statements about the stethoscope are appropriate for the nurse to include in the teaching session? (Select all that apply.)

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 42/min, respiratory rate 14/min, and BP 98/77 mm Hg. Which vital sign should the nurse re-measure?

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?

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which action should the nurse take?

A nurse is preparing a program on osteoporosis for a local women's group. Which of the findings does the nurse recognize as a modifiable risk factor?

A nurse is teaching about the risk factors of developing a stroke with a group of older adult clients. Which nonmodifiable risk factors should the nurse include in the teaching?

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 nurse is assessing a client's circulatory system. Which pulse site should the nurse avoid assessing bilaterally at the same time?