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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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View Related questions

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.

Correct Answer is ["A","D","E"]

Explanation

A. Encouraging the use of an incentive spirometer helps prevent respiratory complications and promotes lung expansion, thereby reducing the risk of infection, particularly pneumonia.

B. While early mobilization is important for recovery, assisting the client out of bed on post-operative day 1 may not be appropriate depending on the patient's condition; this option is not directly related to infection prevention.

C. Repositioning every four hours is important for pressure ulcer prevention but does not directly impact infection risk; more frequent repositioning may be necessary to ensure adequate skin integrity and circulation.

D. Utilizing aseptic technique while changing the dressing is crucial for preventing infection at the surgical site, making this a vital intervention.

E. Maintaining TEDS (thromboembolic deterrent stockings) and SCDs (sequential compression devices) helps prevent deep vein thrombosis (DVT) and improves circulation, which can indirectly reduce infection risk by promoting better blood flow.

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