The nurse is preparing to assess the motor function of the client's trigeminal nerve. Which of the following tests would be most appropriate for the nurse to use?
Have the client smile, frown, and puff out their cheeks
Palpate the masseter muscles when the client clenches their teeth
Assess constriction of the client's pupils with direct and indirect light
Ask the patient to turn their head left and right with resistance
The Correct Answer is B
A) Have the client smile, frown, and puff out their cheeks: This test assesses the facial nerve (cranial nerve VII), not the trigeminal nerve (cranial nerve V). While important for evaluating facial movement, it does not specifically test the motor function of the trigeminal nerve, which is responsible for mastication.
B) Palpate the masseter muscles when the client clenches their teeth: This is the correct test for assessing the motor function of the trigeminal nerve. The trigeminal nerve innervates the muscles responsible for chewing, and palpating the masseter muscles during clenching allows the nurse to evaluate muscle strength and function. It provides insight into the motor capabilities associated with this cranial nerve.
C) Assess constriction of the client's pupils with direct and indirect light: This test evaluates the function of the optic nerve (cranial nerve II) and the oculomotor nerve (cranial nerve III). It does not assess the trigeminal nerve and is not relevant for this assessment.
D) Ask the patient to turn their head left and right with resistance: This action tests the spinal accessory nerve (cranial nerve XI), which is involved in neck movement. It does not relate to the function of the trigeminal nerve, making it an inappropriate choice for this specific assessment.
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Correct Answer is B
Explanation
A) This would indicate pitting edema: Tenting is not indicative of pitting edema, which is characterized by a depression left in the skin after pressure is applied. Tenting specifically refers to the skin's elasticity and is assessed by pinching the skin, observing how quickly it returns to its normal position.
B) This may indicate dehydration, but might not be reliable in an older adult: Tenting is often a sign of dehydration, as it reflects decreased skin elasticity. However, in elderly individuals, skin changes due to aging (like reduced elasticity and moisture) may make this assessment less reliable. Factors such as medications, health status, and overall skin integrity can also influence this observation, making it necessary to consider other indicators of hydration.
C) This means the client is well hydrated: Tenting does not indicate adequate hydration. In fact, it typically suggests the opposite, as well-hydrated skin should return to normal quickly after being pinched.
D) This indicates peripheral neuropathy: While peripheral neuropathy can affect skin and tissue integrity, tenting specifically relates to skin turgor and elasticity rather than nerve function. Tenting is not a direct indicator of neuropathy; other assessments would be needed to evaluate nerve health.
Correct Answer is D
Explanation
A) Occurs only in the clinical area: Focused assessments can be conducted in various settings, including outpatient clinics, home health visits, and emergency departments. Thus, this statement does not accurately define the difference.
B) Involves all body systems: A focused assessment is specifically targeted and does not involve an evaluation of all body systems. Instead, it concentrates on particular areas of concern, making this statement incorrect.
C) Covers the body from head to toe: This describes a comprehensive assessment rather than a focused one. A comprehensive assessment is thorough and covers the entire body, while a focused assessment zeroes in on specific issues or symptoms.
D) More in depth on specific issues: A focused assessment is designed to gather detailed information about particular health problems or concerns rather than providing a broad overview of the patient’s overall health. This targeted approach allows healthcare providers to identify and address specific needs effectively, making this the correct choice.