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 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.
Correct Answer is B
Explanation
A. Observing for facial symmetry assesses cranial nerves VII (facial nerve), not cranial nerve III.
B. Cranial nerve III (oculomotor nerve) is responsible for eye movement and pupillary response, making checking the pupillary response to light the correct action.
C. Testing visual acuity primarily assesses cranial nerve II (optic nerve), not cranial nerve III.
D. Eliciting the gag reflex is associated with cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve III.