Answer to Question 1
C
The trigeminal nerve is tested by lightly touching the cornea with a wisp of cotton, by assessing the corneal reflex, and by measuring sensation of light pain and touch across the skin of the face.
The optic nerve is tested by using the Snellen chart or asking the client to read printed material.
The facial nerve is tested by having the client smile, frown, puff out cheeks, and raise and lower eyebrows while the nurse looks for asymmetry. Having the client identify salty or sweet tastes on the front of the tongue also tests the facial nerve.
The oculomotor nerve is tested by assessing directions of gaze, and testing papillary reaction to light and accommodation.
Answer to Question 2
B
A common physiological change in the older adult client is an increased sensitivity to glare.
Increased tactile responsiveness would not be an expected finding in the older adult client.
An expected physiological change in the older adult client is a loss of hearing acuity for high-frequency tones (presbycusis).
The older adult has decreased thoracic expansion during ventilation because of musculoskeletal changes.
A nurse adjusts the rate of a client’s IV.
The surgical nurse assists the client into the correct position
The nurse uses a noninvasive bladder ultrasound to measure the client’s bladder volume.
Measurement of temporal artery temperature
A step stool can be used to assess the ability to use steps.
Testing client’s ability to identify sharp sensations