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 C
Explanation
A) Third left ICS: The third left intercostal space (ICS) is typically associated with the auscultation of the pulmonic valve rather than the tricuspid valve. While it is in the vicinity of the heart, it is not the correct location for assessing the tricuspid area.
B) Second right ICS: The second right intercostal space is where the aortic valve is best heard. This location is important for assessing blood flow through the aorta, but it is not relevant for the tricuspid valve auscultation.
C) Fourth left ICS: The tricuspid valve is best auscultated at the fourth left intercostal space along the left sternal border. This area allows for optimal listening to the sounds produced by the tricuspid valve, providing important information about right heart function.
D) Second left ICS: The second left intercostal space is the auscultation point for the pulmonic valve, not the tricuspid valve. While this area is critical for assessing the heart, it does not correspond to the location for the tricuspid valve.
Correct Answer is C
Explanation
A) Obtain an order for a catheter: While catheterization can help manage elimination needs, it is generally considered a more invasive approach and is not the first line of action unless absolutely necessary. The goal should be to maintain the client’s dignity and encourage as much independence as safely possible.
B) Allow the client to walk independently: Given that the Romberg test is positive, indicating potential balance issues, allowing the client to walk independently could increase the risk of falls and injury. Safety is a primary concern in this situation.
C) Obtain a bedside commode: This intervention is appropriate as it provides a safe and accessible option for the client to meet their elimination needs without the need to navigate to a bathroom, which may be challenging given their balance issues. A bedside commode allows for easier access while minimizing the risk of falls.
D) Limit fluid intake: Limiting fluid intake is not a safe or effective way to address elimination needs and could lead to dehydration and other complications. Encouraging appropriate fluid intake is important for overall health, provided the client can manage elimination safely.