Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is performing a neurological assessment for a client with head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve II?
A. Instruct the client to look up and down without moving his head.
This is the correct answer because cranial nerve II is the optic nerve, which is responsible for vision. Testing the client's ability to look up and down without moving his head assesses the function of this nerve.
B. Ask the client to shrug his shoulders against passive resistance.
This is incorrect because cranial nerve XI is the accessory nerve, which innervates thetrapezius and sternocleidomastoid muscles. Asking the client to shrug his shoulders against passive resistance tests this nerve.
C. Observe the client's ability to smile and frown.
This is incorrect because cranial nerve VII is the facial nerve, which controls facial expressions. Observing the client's ability to smile and frown tests this nerve.
D. Have the client stand with eyes his closed and touch his nose.
This is incorrect because cranial nerve VIII is the vestibulocochlear nerve, which is involved in balance and hearing. Having the client stand with eyes his closed and touch his nose tests this nerve.
This question is an excerpt from Nurse Dive's nursing test bank - Ati med surg adult care 2 proctored exam. Take the full exam now
Similar Questions
The nurse caring for a client with a brain tumor will monitor for which of the following early signs of increased intracranial pressure?
A. fixed dilated pupil
This is the correct answer because a fixed dilated pupil indicates compression of cranial nerve III, which is an early sign of increased intracranial pressure.
B. lethargy after administration of pain medication
This is incorrect because lethargy after administration of pain medication may be due to the sedative effect of the medication and not necessarily increased intracranial pressure.
C. lack of emotional response
This is incorrect because lack of emotional response may be related to other factors such as depression, anxiety, or personality changes and not necessarily increased intracranial pressure.
D. CheyneStokes breathing pattern
This is incorrect because CheyneStokes breathing pattern is a late sign of increased intracranial pressure, indicating brainstem dysfunction.
A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take?
A. Allow the drainage to drip onto a sterile gauze pad.
This is correct because clear fluid draining from the nose could indicate a cerebrospinal fluid (CSF) leak, which is a serious complication of head trauma. Allowing the drainage to drip onto a sterile gauze pad can help confirm the presence of CSF by observing a halo sign (a yellow ring around a blood spot). It also prevents contamination and infection of the CSF.
B. Obtain a culture of the specimen using sterile swabs
This is incorrect because obtaining a culture of the specimen is not a priority intervention for a client with suspected CSF leak. It could also introduce bacteria into the CSF and causemeningitis.
C. Suction the nose gently with a bulb syringe.
This is incorrect because suctioning the nose could increase intracranial pressure and worsen the CSF leak. It could also damage the nasal mucosa and cause bleeding.
D. Insert sterile packing into the nares.
This is incorrect because inserting sterile packing into the nares could obstruct the drainage of CSF and increase intracranial pressure. It could also cause pressure necrosis of the nasal tissue.
A client newly diagnosed with multiple sclerosis is receiving education about newly prescribed medications from the nurse. Which of the following will be included in the client teaching?
A. Beta blockers are used to treat hypertension.
This is incorrect because beta blockers are not used to treat multiple sclerosis. They are used to treat hypertension, angina, arrhythmias, and other cardiovascular conditions.
B. Antispasmodics are used to treat urinary constipation.
This is incorrect because antispasmodics are not used to treat urinary constipation. They are used to treat urinary frequency, urgency, and incontinence, which are common symptoms ofmultiple sclerosis.
C. Corticosteroids are used to put the disease process into remission.
This is incorrect because corticosteroids are not used to put the disease process into remission.They are used to reduce inflammation and edema during acute exacerbations of multiple sclerosis.
D. Immunomodulators are used to prevent relapses.
This is correct because immunomodulators are used to prevent relapses and slow down the progression of multiple sclerosis. They work by modifying the immune system's response to myelin, which is damaged in multiple sclerosis.