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","C","E"]
Explanation
A) Alert and oriented: Being alert and oriented typically indicates adequate oxygenation, not hypoxia. Patients experiencing hypoxia are more likely to show signs of confusion or altered mental status rather than clarity.
B) Cyanosis: Cyanosis is a classic sign of hypoxia, presenting as a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. This is a significant indicator of inadequate oxygenation.
C) Anxiety and restlessness: These symptoms are common responses to hypoxia as the body attempts to compensate for insufficient oxygen. Patients may feel anxious or restless as they struggle to breathe or feel a sense of impending doom.
D) Oxygen saturation 96%: An oxygen saturation level of 96% is generally considered normal and indicates adequate oxygenation. Therefore, this finding does not suggest hypoxia.
E) Capillary refill 5 seconds: A prolonged capillary refill time can indicate poor perfusion and potential hypoxia. Inadequate blood flow can lead to reduced oxygen delivery to tissues, making this a relevant sign of hypoxia
Correct Answer is A
Explanation
A) Barrel Chest: This term describes a condition where the anterior-posterior (AP) diameter of the chest is equal to the transverse diameter, giving the chest a rounded appearance. This finding is often observed in older adults or individuals with chronic respiratory conditions, and it indicates a potential increase in lung volume and air trapping, commonly seen in conditions like emphysema or chronic obstructive pulmonary disease (COPD).
B) Chronic Obstructive Pulmonary Disease: While barrel chest can be associated with COPD, it is not a direct descriptor of the chest shape. COPD encompasses various symptoms and physiological changes but does not specifically define the chest's physical appearance as barrel-shaped.
C) Anterior/Posterior Distortion: This term does not accurately describe the findings observed in the assessment. While it suggests some alteration in chest shape, it does not specifically refer to the characteristic appearance of barrel chest, which is a well-defined clinical term.
D) Lordosis: This refers to an excessive inward curve of the spine, particularly in the lumbar region. While it may affect posture and overall body alignment, it does not relate to the chest shape or measurements, making it an inappropriate choice in this context.