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The nurse prepares to assess the patient's cranial nerves. Which tool is necessary to assess cranial nerve (CN) III (oculomotor)?

A.

Otoscope

B.

Penlight

C.

Cotton ball

D.

Lavender

Answer and Explanation

The Correct Answer is B

A. An otoscope is used to examine the ear canal and tympanic membrane, not to assess cranial nerve III. This tool is more relevant for assessing cranial nerve VIII (vestibulocochlear), which is responsible for hearing and balance.  

 

B. A penlight is used to assess CN III (oculomotor) by evaluating the pupil's response to light and the ability to move the eye. This nerve controls most of the eye's movements, including constriction of the pupil in response to light.  

 

C. A cotton ball is used to test the sensory function of cranial nerve V (trigeminal), which is responsible for facial sensation. It is not used for assessing CN III.  

 

D. Lavender or other scents may be used to test CN I (olfactory), responsible for the sense of smell, but it is not related to CN III, which governs eye movements and pupil reactions.


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Correct Answer is A

Explanation

A. Stage IV pancreatic cancer often leads to bile duct obstruction, causing decreased bile flow into the intestines. This results in clay-colored stools due to the absence of bile pigments.

B. Hematuria, or blood in the urine, is not a common symptom of pancreatic cancer, even in advanced stages. It is more associated with conditions affecting the urinary system.

C. Jaundice causes dark, concentrated urine rather than pale, dilute urine due to the accumulation of bilirubin in the bloodstream, which is excreted through the kidneys.

D. Weight loss, rather than weight gain, is a common manifestation in clients with advanced pancreatic cancer due to malabsorption and cachexia.

Correct Answer is B

Explanation

A. Requesting antidepressant medication may be appropriate later, but it does not address the immediate need for emotional support and communication.

B. Encouraging the client to verbalize feelings about their diagnosis provides an opportunity for the client to express their concerns and emotions, fostering a therapeutic relationship and aiding in emotional processing.

C. While explaining improved prognosis can provide hope, it may minimize the client’s feelings of fear and uncertainty and could be perceived as dismissive.

D. Allowing time for reflection is important, but it should be balanced with the need for communication and support to prevent isolation.

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