a nurse assisting with data collection is testing the cochlear portion of the acoustic nerve cranial nerve viii which action does the nurse take to te
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Nursing Elites

NCLEX-PN

Health Promotion and Maintenance NCLEX Questions

1. A nurse assisting with data collection is testing the cochlear portion of the acoustic nerve (cranial nerve VIII). Which action does the nurse take to test this nerve?

Correct answer: D

Rationale: To test the cochlear portion of the acoustic nerve (cranial nerve VIII), the nurse should have the client close their eyes and indicate when a ticking watch is heard as the nurse moves the watch closer to the client's ear. This action assesses the client's ability to perceive auditory stimuli, as the cochlear portion of the acoustic nerve is responsible for hearing. Choices A, B, and C are incorrect. Asking the client to raise their eyebrows to check for symmetry is a method to test the facial nerve (cranial nerve VII). Asking the client to clench their teeth and palpating the masseter muscles tests the motor component of the trigeminal nerve. Having the client identify light and sharp touch on both sides of the face is a way to test the sensory component of the trigeminal nerve (cranial nerve V).

2. During a routine office visit, which of the following developmental milestones should the nurse screen for in a 6-month-old child?

Correct answer: B

Rationale: The correct developmental milestone for a 6-month-old child that should be screened during a routine office visit is rolling over. At this age, infants typically start rolling over from their stomach to their back and vice versa. Sitting up usually occurs between 7 and 8 months, creeping between 9 and 10 months, and standing while holding something between 8 and 10 months. Therefore, choices A, C, and D are developmentally appropriate but not typically expected at 6 months of age.

3. While assisting with data collection regarding the neurological system, the nurse asks the client to puff out both cheeks. Which cranial nerve is the nurse assessing?

Correct answer: B

Rationale: The correct answer is B: Facial. Assessment of cranial nerve VII (facial nerve) involves noting mobility and symmetry as the client performs various facial movements, including puffing out the cheeks. Cranial nerve IX (glossopharyngeal nerve) and cranial nerve X (vagus nerve) are tested together for different functions. The abducens, oculomotor, and trochlear nerves are assessed together for eye movements and pupil reactions, not cheek puffing.

4. A teenager is preparing to care for a hospitalized teenage girl who is in skeletal traction. The teenager assists with planning care knowing that which is the most likely primary concern of the teenage girl?

Correct answer: B

Rationale: The correct answer is 'Body image.' Adolescents, especially teenage girls, are often preoccupied with their appearance and body image. When facing a situation like being in skeletal traction, which can affect their physical appearance, body image becomes a primary concern. Concerns about body image can significantly impact their self-esteem and emotional well-being. Choice A, 'Keeping up with schoolwork,' is important but typically not the primary concern in this context. Choices C and D, 'Obtaining adequate rest and sleep' and 'Obtaining adequate nutrition,' are crucial for overall health but are secondary to the significant impact that body image concerns can have on a teenage girl in this situation.

5. When a 16-year-old girl visits the women's health clinic to obtain information about birth control because she is sexually active and wants to avoid pregnancy, what should the nurse do first when interviewing the client?

Correct answer: A

Rationale: When a client seeks information about birth control, it is essential for the nurse to first assess the client's existing knowledge on the subject. This enables the nurse to provide tailored information that complements what the client already knows, facilitating better understanding and decision-making. Providing written material is a helpful educational tool but should not be the first intervention. Offering specific advice on birth control methods based on age and lifestyle limits the client's autonomy and decision-making process. Mentioning the client's boyfriend as a requirement for discussing birth control is inappropriate and nontherapeutic, as the client should be able to seek information independently.

Similar Questions

In conducting a health screening for 12-month-old children, the nurse expects them to have been immunized against which of the following diseases?
A nurse is interviewing an older adult while assisting with data collection. Which client comment regarding vision requires immediate discussion with the health care provider?
A nurse assisting with data collection notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding using which term?
During an interview, what action should a nurse conducting an interview with a client take to collect subjective data?
A client is taking phenelzine (Nardil), and their spouse would like to bring lunch from home. Which of the following is most appropriate for the client to eat?

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