When hearing is evaluated, which cranial nerve is being tested?
VII
X
I
II
The Correct Answer is A
A. Cranial nerve VII (facial nerve) is not primarily responsible for hearing; however, it does have some sensory function in the ear region. The primary cranial nerve responsible for hearing is cranial nerve VIII (vestibulocochlear), which is not listed among the options.
B. Cranial nerve X (vagus nerve) is primarily involved in autonomic functions and does not directly relate to hearing.
C. Cranial nerve I (olfactory nerve) is responsible for the sense of smell.
D. Cranial nerve II (optic nerve) is responsible for vision.
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Correct Answer is D
Explanation
A. The tympanic temperature of 37.1° C (98.8° F) is within normal limits and does not require re-measurement.
B. The respiratory rate of 14/min is also within the normal range (12-20 breaths per minute).
C. The blood pressure of 98/77 mm Hg is not alarmingly low and does not require immediate re-measurement.
D. A pulse rate of 42/min indicates bradycardia (normal resting heart rate is typically between
Correct Answer is B
Explanation
A. The planning phase involves setting goals and determining interventions based on the assessment data.
B. The assessment phase is where the nurse gathers information about the client's health history, including potential allergies, which is essential for safe care and diagnostic testing.
C. The implementation phase involves carrying out the planned interventions, which would include considerations for allergies but not the initial questioning about them.
D. The evaluation phase assesses the effectiveness of the interventions and the client's response to care, which is not the appropriate time to inquire about allergies.