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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.

Response to verbal stimuli

B.

Affect, feelings, or emotions

C.

Eye movements

D.

Insight, judgment, and planning

Answer and Explanation

The Correct Answer is C

A. Response to verbal stimuli does not directly assess the function of cranial nerves III, IV, and VI.  

 

B. Affect, feelings, or emotions are related to the assessment of other neurological functions and do not evaluate the ocular cranial nerves specifically.  

 

C. Eye movements are the primary function of cranial nerves III (oculomotor), IV (trochlear), and VI (abducens), which control eye movement and provide essential information about their function.  

 

D. Insight, judgment, and planning relate more to cognitive function and do not directly assess the function of the cranial nerves in question.


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View Related questions

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

Explanation

A. Decreased urine output: While not a direct sign of pneumonia, decreased urine output can be an objective finding indicative of dehydration, which often accompanies infections like pneumonia.

B. Headache: Although the client has a headache, it is a subjective symptom rather than an objective finding and is not a primary indicator of pneumonia.

C. Respiratory assessment: The respiratory assessment reveals shortness of breath, crackles in the right lower lobe, and tachypnea, which are commonly associated with pneumonia.

D. Chest X-ray: The chest X-ray shows areas of increased density and infiltrates in the right lower lobe, a hallmark finding that indicates pneumonia.

E. Religion: This does not relate to the clinical findings associated with pneumonia.

F. Bowel sounds: Normal bowel sounds are not indicative of pneumonia.

G. Perception of needles: This is irrelevant to the diagnosis of pneumonia.

Correct Answer is A

Explanation

A. Having the child bend at the waist allows the nurse to observe the spine for any abnormal curvature indicative of scoliosis, such as uneven shoulders or a rib hump.

B. Measuring the distance between the knees and the ankles is not a technique used to screen for scoliosis; it is more related to assessing leg length discrepancies.

C. Measuring the length of each leg does not assess for scoliosis but is more relevant for evaluating leg length inequalities.

D. Asking the child to walk across the room is useful for assessing gait and balance but does not directly assess for scoliosis.

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