NURS 315 Exam 4 Questions from LM and Cranial Nerves

An adult client tells the nurse that his 80 y/o father is almost completely deaf. After an explanation to the client about risk factors for hearing loss, the nurse determines that the client needs further instruction when the client says...

"It is difficult to prevent hearing loss or worsening of hearing loss."

The nurse assess an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually to prevent a...

A reduction of blood supply to the brain

Cranial Nerve 6

Abducens and motor

The functional reflex that allows the eyes to focus on near objects is termed...

Accommodation

Cranial Nerve 8

Acoustic/vestibulocochlear and sensory

While assessing an adult client's skull, the nurse observes that the client's skull and facial bones are larger and thicker than usual. The nurse should assess the client for...

Acromegaly

After examining the client's TM, the nurse documents "R TM red and bulging with no light reflex." The nurse recognizes that these are signs of...

Acute otitis media

An adult client tells the nurse that she frequently experiencing during and itching of both eyes. The nurse should assess the client for...

Allergies

An adult client visits the clinic complaining of recurrent ulcers in the mouth. The nurse assess the client's mouth and observes a painful ulcer. The nurse should document the presence of...

Aphthous stomatitis

The nurse is planning to assess an adult client's thyroid gland. The nurse should plan to...

Approach the client posteriorly

The nurse is assessing an adult client's oral cavity for possible oral CA. The nurse should explain to the client that the most common site of oral CA is the...

Area underneath the tongue

The nurse is assessing the mouth of an older adult and observes that the client appears to have poorly fitting dentures. The nurse should instruct the client that she may be at greater risk for...

Aspiration

During the PE of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiologic cause for this finding is related to what disease process?

Atelectasis

A nurse is assessing a client with hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use?

Auscultation

The conjunctiva of the eye is divided into the palpebral portion and the

Bulbar portion

The nurse is assessing a client who has been taking abc for an infection for 10 days. The nurse oversees whitish curd-like patches in the client's mouth. The nurse should explain to the client that these spots are most likely...

Candida albicans infection (yeast)

An adult client tells the nurse that he has been experiencing gradual vision loss. The nurse should...

Check the client's blood pressure

Before examining the mouth of an adult client, the nurse should first...

Don clean gloves for the procedure

While assessing the eye of an adult client, the nurse observes an inward Turing of the client's L eye. The nurse should document the client's...

Esotropia

The cone of light is located in the...

External ear

The tongue is attached to the hyoid bone and styloid process of the temporal bone and is connected to the floor of the mouth by the...

Frenulum

The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the...

Glossopharyngeal

Cranial Nerve 9

Glossopharyngeal and both

An adult client visits the clinic and tells the nurse that she has had a sudden change in her vision. The nurse should explain to the client that sudden changes in vision are often associated with...

Head trauma

An adult client visits the clinic and tells the nurse that he has been experiencing double vision for the past few days. The nurse refers the client to a physician for evaluation of possible...

Increase intracranial pressure

An adult client visits the clinic and tells the nurse that he has had excessive tearing in his L eye. The nurse should assess the client's eye for...

Lacrimal obstruction

The tarsal plates of the upper eyelid contain...

Meibomian glands

A female client visits the clinical and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea an vomiting. The nurse determines that the type of headache the client is describing is a...

Migraine headache

The nurse is planning to perform an ear examination on an adult client. After explaining the procedures to the client, the nurse should...

Observe the client's response to the explanations

Cranial Nerve 3

Oculomotor and motor

While assessing the pupils of a hospitalized adult client, the nurse observes that the client's pupils are dilated to 6cm. The nurse suspects that the client is exhibiting signs of...

Oculomotor paralysis

A nurse needs to palpate a client's submandibular lymph nodes. Where should the nurse place her hands to do this?

On the medial border of the mandible

Cranial Nerve 2

Optic and sensory

The optic nerves from each eyeball cross at the...

Optic chiasma

While assessing an adult client's head and neck, the nurse observes asymmetry in front of the client's ear lobes. The nurse refers the client to the physician because the nurse suspects the client is most likely experiencing a/an...

Parotid gland enlargement

A client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional information should the nurse collect?

Previous injuries to the head and neck

Straight movements of the eye are controlled by the...

Rectus muscles

Photoreceptors of the eye are located in the eye's...

Retina

The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to...

Sit in an upright position

The root of the oral cavity of the mouth is formed by the anterior hard palate and the...

Soft palate

Sensory receptors in the ear that help to maintain both static and dynamic equilibrium are located in the semicircular canals and the...

Vestibule

The rich blood supply of the nose serves to...

Warm the inspired air

The meibomian glands secrete...

an oily substance to lubricate the eyes

The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should...

position the client 609.6 cm (20 ft) away from the chart.

The body orbit and fat cushion of the eye serves as a...

protector

A nurse assess the mouth of an adult male client and observes a rough, crusty, eroded area. The nurse should...

refer the client for further evaluation

While assessing the ears of an adult client, the nurse observes bloody drainage in the client's ear. The nurse should...

refer the client to a physician

An older client visits the clinic accompanied by his daughter. The daughter tells the nurse that her father has been experiencing severe headaches that usually begin in the morning and become worse when he coughs. The client tells the nurse that he feels dizzy when he has the headaches. The nurse refers the client for further evaluation because these symptoms are characteristic of a...

tumor related headache

The nurse is caring for a healthy adult client with no hx of vision problems. The nurse should tell the client that a thorough eye examination is recommended every...

2 years

The nurse is assessing the neurologic system of an adult client. To test the client's motor function of the facial nerve, the nurse should...

Akse he client to purse the lips

The nurse has assessed the nose of an adult client and has explained to the client about her which yellowish nasal discharge. The nurse determines that the client understand the instruction when the client says that the yellowish discharge is mostly likely due to...

An URI

The nurse is preparing to perform a head and neck assessment of an adult client who has immigrate to the US from Cambodia. The nurse should first...

Ask the client if touch the head is permissible

The chambers of the eye contain aqueous humor, which helps to maintain interocular pressure and...

Cleanse the cornea and the lens

While assessing the eyes of an adult client, the nurse uses a wisp of cotton to stimulate the client's...

Corneal reflexes

The nurse has tested the near visual acuity of a 45 year old client. The nurse explains to the client that the client has impaired near vision and discusses a possible reason for the condition. The nurse determines that the client has understood the instructions when the client says that presbyopia is usually due to...

Decreased accommodation

The nurse is planning to inspect an adult client's mouth, using a tongue depressor. The nurse should plan to...

Depress the tongue blade slightly off center.

The nurse is planning a presentation to a group of high school students about the risk factors for oral cancer. Which of the following should be included in the nurse's plan?

Diets low in fruits and vegetables are a possible risk factor for oral CA

The nurse has tested an adult client's visual fields and determined the the temporal field is 90 degrees in both eyes. The nurse should...

Document the finding in the client's records

Cranial Nerve 7

Facial and both

The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses, the nurse should process to examine the...

Maxillary sinuses

A client presents to the ED with reports of neck pain and a sudden onset of a HA. Upon examination, the nurse finds that the client has an increased temperature and neck stiffness. The nurse recognizes these finding as most likely to be caused by what condition?

Meningeal inflammation

A client visits the outpatient center with a complaint of sudden head and neck pain and stiffness. The client's oral temperature is 37.7C. The nurse suspects the client is experiencing symptoms of...

Meningeal irritation

Which action by the nurse demonstrates correct assessment of the corneal reflex of a client during an eye examination?

Touch the cornea with a wisp of cotton

Cranial Nerve 5

Trigeminal and both

An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. The nurse should instruct the client that a potential risk factor is...

UV exposure

A client tells the nurse that she has difficulty seeing while driving at night. The nurse should explain to the client that night blindness is often associated with...

Vitamin A deficiency

While assessing the ears of an adult client, the nurse observes that the TM is completely immobile. The nurse should further assess the client for signs and symptoms of...

infection

What does cranial nerve 10 do?

Carries sensations from the throat, larynx, heart, lungs, bronchi, GI tract, and abdominal viscera. Promotes swallowing, talking, and production of digestive juices.

What does cranial nerve 5 do?

Carries sensory impulses of pain, touch, and temperature from the face to the brain. Influences clenching and lateral jaw movements (bitting and chewing).

What does cranial nerve 1 do?

Carries smell impulses from nasal mucous membrane to brain.

What does cranial nerve 2 do?

Carries visual impulses from eye to brain.

The middle later of the eye is known as the...

Choroid layer

An adult client visits the clinic and tells the nurse that she has had headaches recently that are intense and stabbing and often occur in the late evening. The nurse should suspect the presence of...

Cluster headaches

The transmission of sound waves through the external ear and the middle ear is known as...

Conducive hearing

The nurse has performed the Rinne test on an older adult client. After the test, the client reports that her bone conduction sound was heard longer than the air conduction sound. The nurse determines that the client is most likely experiencing...

Conductive hearing loss

What does cranial nerve 3 do?

Contacts eye muscles to control eye movements (inferior lateral, medial, and superior), constricts pupils, and elevates eyelids.

What does cranial nerve 7 do?

Contains sensory fiber for Tate on anterior two thirds of tongue, and stimulates secretions from salivary glands (submaxillary and sublingual) and tears from lacrimal glands. Supplies the facial muscles and affects facial expressions (smiling, frowning, and closing eyes).

What does cranial nerve 9 do?

Contains sensory fibers for Tate on posterior third of tongue and sensory fibers of the pharynx that result in the gag reflex when stimulated. Provides secretory fibers to the parotid salivary glands; promotes swallowing movements.

What does cranial nerve 8 do?

Contains sensory fibers for hearing and balance.

What does cranial nerve 4 do?

Contracts one eye muscle to control infer medial eye movement.

What does cranial nerve 6 do?

Controls lateral eye movement

An adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to...

Corneal damage

The nurse is preparing to examine the ears of an adult client with an otoscope. The nurse should plan to...

Firmly pull the auricle out, up, and back

In the hearing pathway, hair cells of the spiral organ of Corti are stimulated by movement of...

Fluid

An adult client visits the outpatient clinic and tells the nurse that he has throbbing aching pain in his R eye. The nurse should assess the client for...

Foreign body in the eye

An adult client tells the nurse that her peripheral vision is not what is used to be and she has a blind spot in her L eye. The nurse should refer the client for evaluation of possible...

Glaucoma

A female client visits the clinic and tells the nurse that she wants to "stay healthy." The nurse observes that the client has diffuse neck enlargement, is perspiring, and is quite fidgety. The client tells the nurse that she is "hungry all the time, but I have to lose weight." A priority nursing diagnosis for the client is...

Health-seeking behaviors related to verbalization of wanting to stay healthy and concerns over weight loss

Cranial Nerve 12

Hypoglossal and motor

What does cranial nerve 11 do?

Innervates neck muscles (sternocleidomastoid and trapezius) that promote movement of the shoulders and head rotation. Also promotes some movement of the larynx.

What does cranial nerve 12 do?

Innervates tongue muscles that promote the movement of food and talking.

Which cranial nerve is the nurse testing when the client is asked to ID a scented object?

Olfactory

Cranial Nerve 1

Olfactory and sensory

Transmission of sound waves in the inner ear is known as...

Perceptive hearing

The nurse is preparing to inspect the nose of an adult client with an otoscope. The nurse plans to...

Position the handle of the otoscope to one side

An adult client visits the clinic and tells the nurse that she has been experiencing frequent nosebleeds for the past month. The nurse should...

Refer the client for further evaluation

While assessing an older adult client's neck, the nurse observes that the client's trachea is pulled to the left side. The nurse should....

Refer the client to a physician for further evaluation

A client visits the local clinic after experiencing head trauma. The client tells the nurse that he has a consistent blind spot in his R eye. The nurse should...

Refer the client to an ophthalmologist

A client has tested a 20/40 on the distant visual acuity test using a Snellen chart. The nurse should...

Refer the client to an optometrist

The nurse is examining an adult client's eyes. The nurse has explained the positions test to the client. The nurse determines that the client needs further instruction when the client says that the positions test...

Requires the covering of each eye separately

A client visits the clinic and tells the nurse that she has painful cracking in the corners of her lips. The nurse should assess the client's diet for a deficiency of...

Riboflavin

Cranial Nerve 11

Spinal accessory and motor

The ossicles contained in the middle ear include the malleus, the incus, and the...

Stapes

An adolescent client tells the nurse that her mother says she grinds her teeth when she sleeps. The nurse should explain to the client that grinding the teeth may be as sign of...

Stress and anxiety

The nurse is planning to conduct the Weber test on an adult male client. To perform this test, the nurse should plan to...

Strike a tuning fork and place it on the enter of the client's head or forehead

The nurse is preparing to assess the neck of an adult client. To inspect movement of the client's thyroid gland, the nurse should ask the client to...

Swallow a small sip of water

An adult client visits the clinic and complains of tints. The nurse should ask the client if she has been...

Taking abx

A 45 year old client tells the nurse that he occasionally sees spots in front of his eyes. The nurse should...

Tell the client that these often occur with age

A client visits the clinic and tells the nurse that he is depressed because of a recent job loss. He complain of dull, aching, tight, and diffuse headaches that have lasted for several days. The nurse should recognize that there are symptoms of...

Tension headaches

Ana dult client visits the clinic complaining of a sore throat. After assessing the throat, the nurse documents the client's tonsils as 4+. The nurse should explain to the client that 4+ tonsils are present when the nurse observes tonsils that are...

Touching each other

While assessing the head and neck of an adult client, the client tells the nurse that she has been experiencing sharp shooting facial pain that lasts from 10-20 seconds but are occurring more frequently. The nurse should refer the client for possible...

Trigeminal neuralgia

Cranial Nerve 4

Trochlear and motor

An extension of the soft palate of the mouth, which hands in the posterior midline of the oropharynx is the...

Uvula

Cranial Nerve 10

Vagus and both

The submandibular glands open under the tongue through openings called...

Wharton Ducts