Question

16. The nurse is testing the function of a mune is testing the function of CN 30-year-old female She is e to feel the sensation on the Themenow that which of her CN is intact a) CNM b) CN IV c) CNV d) CN VII 17. The nurse is conducting a health history on a new client. The client presents with complaints of chest pain. The nurse will document this in which of the following area in the health history? a) Reason for seeking care b) History of present illness c) Past health d) Review of systems 18. Which technique is correct when the nurse is assessing the radial pulse of a client? a) Count for 15 seconds and then multiply by 4. If the patient has no cardiac abnormalities b) Use 3 finger pads to palpate along flexor aspect of wrist laterally along the radial bone c) If the rhythm is irregular, count for 30 seconds and multiply by 2 d) If the rhythm is regular, count for 15 seconds and multiply by 4 19. When measuring a client's blood pressure, the nurse recalls that certain factors help determine blood pressure. Which of the following is a false statement? a) Increased blood volume leads to increased blood pressure b) Increased peripheral vascular resistance leads to increased blood pressure c) Increased viscosity of blood leads to increased blood pressure d) Increased elasticity of vessel walls leads to increased blood pressure 20. The nurse notices a colleague is preparing to check the blood pressure of a client who is lying on their left side by using the right arm of the client (right arm is located above the heart). The nurse should expect the reading to: a) Yield a falsely low blood pressure b) Yield a falsely high blood pressure c) Be the same, regardless of the position of the client's arm d) Vary as a result of the technique of the person performing the assessment

Answer 1

16. Answer ; d) CN VII
  Rationale ; This part of cranial nerve provide sensory information to the brain of that women, when the nurse touches her
face.

!7. Answer ; b) History of present illness
Rationale ; While nurse getting information as client has current complaint of that particular pain, the nurse tends to
document in the place specified for present illness. Other options are not relevance to the finding she made there.

!8. Answer ; d) If the rhythm is regular, count for 15 seconds and multiply by 4
Rationale ; While doing this assessment, the nurse may check whether it is regular or irregular, if it is regular and easily
felt by the nurse, it can be measured by above mentioned way. If not then she need to count the beats for
complete one minutes without any multiplication.

19. Answer ; d) Increased elasticity of the vessel wall leads to increased blood pressure

20. Answer ; c) Be the same regardless of the position of the client arm