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 D
Explanation
A) "Have you ever had any surgeries?": While this question is important, it is more specific and may not provide the comprehensive context needed to guide the interview. It could lead to a narrow focus on past surgical history without addressing the client’s current health status or concerns.
B) "Tell me about any medical problems that you have had.": This question is useful but lacks the immediate relevance to the client's current situation. It may prompt the client to recount past issues rather than focusing on their current health needs and reasons for seeking care.
C) "Tell me about any medications you are currently taking.": This is an essential aspect of health history, but like the previous options, it doesn't address the client’s immediate concerns or symptoms that may guide the rest of the interview.
D) "Tell me why you are seeking care today.": This question is the most effective starting point as it directly addresses the client’s current health issue or concern. Understanding the reason for seeking care helps the nurse prioritize topics, gather relevant information, and tailor the rest of the health history interview to the client’s specific needs, making it a crucial guide for further questioning.
Correct Answer is A
Explanation
A) Report the abuse according to facility policy: The nurse has a legal and ethical responsibility to report suspected or disclosed abuse or neglect immediately, following the facility's protocols and state laws. This ensures that appropriate action is taken to protect the vulnerable individual and provides necessary interventions.
B) Consider a referral to social services: While this may be part of the broader care plan, the immediate priority is to report the abuse. Social services can be involved after the initial reporting to ensure that the appropriate support systems are put in place for the individual.
C) Meet with the patient's family: Meeting with the family may be relevant in some cases, but it is not the nurse's primary responsibility upon disclosure of abuse. Involving family members can sometimes complicate situations, especially if they are involved in the abuse.
D) Contact the primary care provider: While informing the primary care provider may be necessary as part of ongoing care, the urgent responsibility is to report the abuse to the proper authorities. The healthcare provider can then be informed as part of the care coordination after the initial report is made.