During the neurological component of the physical examination, the nurse tests the function of the client's cranial nerves. In testing cranial nerve III, the nurse determines the client's ability to do which one of the following?
a. Smile and frown
b. Read printed material
c. Identify sweet and sour tastes
d. React to light with changes in pupil size
D
In testing cranial nerve III (oculomotor), the nurse determines the client's ability to react to light with changes in pupil size. Testing accommodation also will assess cranial nerve III.
In testing cranial nerve VII (facial), the nurse determines the client's ability to smile and frown.
In testing cranial nerve II (optic), the nurse determines the client's ability to read printed material.
In testing cranial nerve IX (glossopharyngeal), the nurse determines the client's ability to identify sweet and sour tastes.
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A patient is undergoing testing to see if he has a pleural effusion. Which of the nurse's respiratory assessment findings would be most consistent with this diagnosis?
A) Increased tactile fremitus, egophony, and a dull sound upon percussion of the chest wall B) Decreased tactile fremitus, wheezing, and a hyperresonant sound upon percussion of the chest wall C) Lung fields dull to percussion, absent breath sounds, and a pleural friction rub D) Normal tactile fremitus, decreased breath sounds, and a resonant sound upon percussion of the chest wall
A patient requires neuromuscular blockade (NMB) as part of treatment of refractive increased intracranial pressure. The nursing care for this patient includes: (Select all that apply.)
a. administration of sedatives concurrently with neuromuscular blockade. b. dangling the patient's feet over the edge of the bed and assisting the patient to sit up in a chair at least twice each day. c. ensuring that deep vein thrombosis prophylaxis is initiated. d. providing interventions for eye care, oral care, and skin care.
The nurse is working with an adolescent who will be admitted to the hospital in 2 days. Which is the most appropriate nursing intervention to prepare the adolescent for hospitalization? Select all that apply
1. Provide the adolescent with written material about the hospitalization. 2. Provide an opportunity for the adolescent to talk with a peer who has had a similar experience. 3. Teach the parents what to expect, so the information can be shared with the adolescent. 4. Provide an opportunity for the teen to try on surgical attire. 5. Explain the adolescent's upcoming surgery using an anatomically correct doll.
After interviewing the mother of an 8-year-old girl with a broken arm, the nurse identifies the mother as the nurturer in the family
When developing the teaching plan for the girl and her mother, the nurse integrates knowledge of this role and focuses the teaching on which of the following? A) Teaching proper care procedures B) Dealing with insurance coverage C) Determining success of treatment D) Transmitting information to family members