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. Assessing the pedal pulses does not provide relevant information about the irregularity of the radial pulse.
B. Assessing the apical pulse for a full minute is appropriate in this situation, as it provides a more accurate measurement of the heart rate and rhythm, especially when the radial pulse is irregular.
C. Assessing the popliteal pulses with a Doppler device is not necessary and does not directly address the irregular radial pulse.
D. While a pulse oximeter can provide information about oxygen saturation, it does not assess heart rate or rhythm.
Correct Answer is C
Explanation
A. Restlessness is an objective sign that may indicate pain, but it is not a subjective report from the client.
B. Pupil dilation is an objective physiological response often associated with pain or stress, not a subjective indicator.
C. A report of a burning sensation is a subjective indicator because it is based on the client’s own description of their pain experience.
D. Grimacing is an objective observation by the nurse, not a subjective report from the client.