A client has paralysis of the right medial rectus muscle of the right eye. Which assessment finding assists the nurse in validating this diagnosis?
a. Client is unable to turn the eye in toward the nose.
b. Client is unable to lift the upper eyelid.
c. Client cannot look downward.
d. Client cannot look upward.
A
Contraction of the medial rectus muscle turns the eye toward the nose. The superior oblique muscle pulls the eye downward, and the inferior oblique muscle pulls the eye upward. The ocular muscles do not lift the upper eyelid.
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One of the things that you can do if you experience powerlessness is:
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A patient is diagnosed with an acute myocardial infarction and ruptured papillary muscle. Which action is the highest priority for the nurse to complete?
1. Obtain an electrocardiogram. 2. Measure the patient's cardiac output. 3. Assess the patient's neurological status. 4. Assess respiratory status.
Which equipment will the nurse obtain to perform a Rinne test?
a. Otoscope b. Tuning fork c. Audiometer d. Ticking watch