NURS 304 Sherpath Lesson Exam 2 – Questions With A+ Solutions

NURS 304 Sherpath Lesson Exam 2 – Questions
With A+ Solutions

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Terms in this set (101)

,Which of these measures of visual Ans: 1, 2, 3, 4, 5
acuity would the nurse assess when
testing the optic nerve (CN II)? Select Far vision
all that apply. Far vision is a measure of visual acuity that the nurse
would examine when testing the optic nerve (CN II).
1. Far vision
2. Near vision Near vision
3. Visual fields Near vision is a measure of visual acuity that the
4. Size of the optic disc nurse would examine when testing the optic nerve
5. Shape of the optic disc (CN II).
6. Texture of the optic disc
Visual fields
The nurse would test visual fields using confrontation.
This is a measure of visual acuity that would be
assessed during testing of the optic nerve (CN II).


Size of the optic disc
The nurse would use the ophthalmoscope to
examine the ocular fundus to determine the size of
the optic disc. This will help the nurse to assess visual
acuity when testing the optic nerve (CN II).


Shape of the optic disc
The nurse would use the ophthalmoscope to
examine the ocular fundus to determine the shape of
the optic disc. This will help the nurse to assess visual
acuity when testing the optic nerve (CN II).


Texture of the optic disc
The texture of the optic disc is not something the
nurse would examine to assess visual acuity when
testing the optic nerve (CN II). The texture of the
optic disc is not relevant to measurement of visual
acuity.

,The nurse would inspect which aspect Ans: 4
of the eyelids as part of the
assessment of the cranial nerves of Color
the eyes? The color of the eyelid would be assessed on
inspection, but it is not part of the assessment of the
1. Color cranial nerves of the eye.
2. Temperature
3. Ability to retract Temperature
4. Tendency to droop The temperature of the eyelid is a palpation finding
and is not part of the assessment of the cranial
nerves of the eyes.


Ability to retract
The ability of the eyelid to retract would be assessed
on inspection, but it is not part of the assessment of
the cranial nerves of the eye.


Tendency to droop
The tendency for the eyelids to droop is an important
part of the assessment of the cranial nerves of the
eyes.


Which elements would the nurse Ans: 1
assess to evaluate cranial nerve XII?
Speech sounds
1. Speech sounds The nurse would evaluate the quality of lingual
2. Smell speech sounds to assess cranial nerve XII.
3. Vision
4. Swallowing Smell
The nurse would assess a patient's smell to evaluate
cranial nerve I, not XII.


Vision
The nurse would assess a patient's vision to evaluate
cranial nerve II, not XII.


Swallowing
The nurse would assess a patient's ability to swallow
to evaluate cranial nerve IX, not XII.

, Which elements should be assessed Ans: 1, 3
to evaluate the glossopharyngeal
nerve (CN IX)? Select all that apply. Gag reflex
The nurse would assess the patient's gag reflex to
1. Gag reflex evaluate the glossopharyngeal nerve.
2. Hearing
3. Swallowing Hearing
4. Secretion of saliva The nurse would assess the patient's hearing to
5. Ability to turn head evaluate cranial nerve VIII, not IX.


Swallowing
The nurse would assess the patient's ability to
swallow to evaluate cranial nerve IX as it innervates
the muscles used to swallow.


Secretion of saliva
The nurse would assess a patient's secretion of saliva
to evaluate cranial nerve VII, not IX.


Ability to turn head
The nurse would assess the patient's ability to turn
the head to evaluate cranial nerve XI, not IX.