The nurse is preparing to assess a client's cranial nerves. Which of the following techniques should you use to assess cranial nerve III?
A) Shine a bright light in the client's eye and observe for bilateral pupillary response.
B) Ask the client to close the eyes, occlude a nostril, then identify the smell of different substances.
C) Determine visual acuity using a Snellen chart
D) Occlude the patient's right ear, whisper a word into the left ear, and ask the patient to repeat it.
Ans: A
This technique is used to assess CN VIII (Acoustic).
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Within the scope of nursing practice is:
1. Performing procedures that provide data for diagnosis and assessment. 2. Acting independently to care for clients. 3. Making sure others take care of one's clients. 4. Performing any duty assigned, regardless of experience.
Which of the following is a positive interpretation of body language?
A) Clenched jaw B) Tilt of head C) Arms crossed D) Rubbing nose
The nurse is instructing a young client on avoiding toxic shock syndrome. Education was successful when the client makes which statements? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply
1. "I will wash my hands before inserting a tampon." 2. "I will change my tampon every 3-6 hours." 3. "I will not touch the part of the tampon I insert." 4. "I will just put the used tampon in the trash." 5. "I will take prophylactic antibiotics if needed."
Which of the following sites would be the most appropriate choice to use to measure a client's temperature who has a history of heart disease and has just eaten a bowl of vegetable soup?
1. Axilla 2. Oral 3. Popliteal 4. Rectal