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) Chronic pain: Chronic pain is defined as pain that lasts for an extended period, often longer than three months, and is usually associated with conditions that are ongoing or recurring. The client’s symptoms, including sudden-onset severe pain and accompanying acute symptoms like nausea and vomiting, do not align with the characteristics of chronic pain.
B) Intractable pain: Intractable pain refers to pain that is resistant to treatment and does not respond well to analgesics or other interventions. While the client's pain is severe, the sudden onset and associated symptoms suggest a specific acute process rather than a pain condition that is inherently resistant to treatment.
C) Acute pain: Acute pain is characterized by its sudden onset and typically corresponds to a specific injury or condition, often with accompanying physiological responses such as nausea and restlessness. The client’s severe pain rating of 10, along with nausea and vomiting, strongly indicates that they are experiencing acute pain, likely related to an underlying acute abdominal condition.
D) End-of-life pain: End-of-life pain usually occurs in patients with terminal illnesses and is often managed with palliative care strategies. The client’s sudden onset of severe pain and accompanying symptoms indicate a different situation, likely not related to a terminal condition.
Correct Answer is B
Explanation
A) Muscle strength: While muscle strength can influence gait, it specifically refers to the ability of muscles to exert force against resistance. Assessing muscle strength involves different techniques, such as manual muscle testing, rather than observing arm and leg movements.
B) Gait: The observation that both arms swing freely in alternation with leg swings is a direct assessment of the patient's gait. A normal gait pattern includes coordinated movements of the arms and legs, indicating proper motor function and balance.
C) Alignment: This term refers to the positioning of the body and its parts in relation to one another. While alignment can impact gait, it is not specifically assessed by observing the movement of the arms and legs.
D) Joint function: Joint function assessment typically focuses on the range of motion, stability, and mobility of individual joints. Observing the swing of arms and legs provides insight into overall gait rather than specific joint function.