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?
Response to verbal stimuli
Affect, feelings, or emotions
Eye movements
Insight, judgment, and planning
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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Correct Answer is B
Explanation
A. Asystole: Asystole would show a flat line with no electrical activity, which is not seen here.
B. Ventricular fibrillation: Ventricular fibrillation is characterized by chaotic, irregular waveforms without distinct P waves, QRS complexes, or T waves. The ECG strip shows this disorganized, erratic electrical activity consistent with ventricular fibrillation.
C. Sinus tachycardia: Sinus tachycardia would display a regular rhythm with identifiable P waves, QRS complexes, and T waves at a faster rate. This is not present in the ECG strip.
D. Sinus bradycardia: Sinus bradycardia would show a slower rate but with an organized rhythm and distinct P, QRS, and T waves. This is not indicated in the strip.
Correct Answer is B
Explanation
A. Observing for facial symmetry assesses cranial nerves VII (facial nerve), not cranial nerve III.
B. Cranial nerve III (oculomotor nerve) is responsible for eye movement and pupillary response, making checking the pupillary response to light the correct action.
C. Testing visual acuity primarily assesses cranial nerve II (optic nerve), not cranial nerve III.
D. Eliciting the gag reflex is associated with cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve III.