When completing a neurological assessment, which cranial nerves are tested within the mouth?
III, IV, VIII
III, II, VI
IX, X, XII
I, I, III
The Correct Answer is C
A. Cranial nerves III, IV, and VIII are not involved in mouth functions; they primarily deal with eye movements and hearing.
B. Cranial nerves III, II, and VI are involved in vision and eye movement but not in mouth functions.
C. Cranial nerves IX (glossopharyngeal), X (vagus), and XII (hypoglossal) are all tested through functions such as swallowing, speech, and movement of the tongue, which occur in the mouth.
D. Option D incorrectly lists cranial nerve I twice; cranial nerve I (olfactory) is related to the sense of smell, not the mouth.
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Correct Answer is A
Explanation
A. Asking the client to identify scented aromas assesses cranial nerve I (olfactory nerve), which is responsible for the sense of smell.
B. Reading a Snellen chart assesses cranial nerve II (optic nerve), which is related to vision.
C. Listening to the client's speech evaluates the function of cranial nerves V (trigeminal) and XII (hypoglossal), which are related to mastication and tongue movement, respectively.
D. Asking the client to clench his teeth tests cranial nerve V, which innervates the muscles of mastication.
Correct Answer is D
Explanation
A. Petechiae are small, pinpoint hemorrhages and are considered objective data that can be observed and documented by the nurse.
B. Blood pressure is a vital sign and objective data that can be measured using a sphygmomanometer.
C. Cyanosis is a physical sign indicating low oxygenation in the blood and is objective data that can be observed.
D. Nausea is a subjective symptom reported by the client, reflecting their internal experience and cannot be measured or observed directly.