a nurse is preparing to assess the acoustic nerve during a neurological examination to assess this nerve the nurse uses which technique a nurse is preparing to assess the acoustic nerve during a neurological examination to assess this nerve the nurse uses which technique
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Nursing Elites

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2024 Nclex Questions

1. A healthcare provider is preparing to assess the acoustic nerve during a neurological examination. To assess this nerve, the provider uses which technique?

Correct answer: Uses a tuning fork

Rationale: Testing of cranial nerve VIII (acoustic nerve) involves assessing hearing acuity through techniques like the whispered voice test and tuning fork tests (Weber and Rinne). Using a tuning fork helps determine if sound lateralizes to one ear (Weber) and compares air conduction to bone conduction (Rinne). Asking the client to puff out the cheeks is for cranial nerve VII (facial nerve) function evaluation. Testing taste perception on the tongue assesses cranial nerve IX (glossopharyngeal nerve) function. Checking the ability to clench teeth assesses cranial nerve V (trigeminal nerve) motor function.

2. What is the best nursing diagnosis for a client with newly diagnosed Diabetes Mellitus?

Correct answer: Knowledge Deficit: New Diabetes Diagnosis

Rationale: The correct answer is 'Knowledge Deficit: New Diabetes Diagnosis.' Newly diagnosed diabetics require education on their disease, medications, glucose testing, insulin injections, foot care, and sick-day plans. Choices A and D aim to prevent issues that do not currently exist for the client. Choice C, 'Alteration in Nutrition: More than Body Requirements,' is not the priority diagnosis for a newly diagnosed diabetic. While nutritional adjustments may be required for type I or type II diabetes, providing knowledge and education takes precedence at this stage.

3. A client scheduled for surgery tells the nurse that he signed an informed consent for the surgical procedure but was never told about the risks of the surgery. The nurse serves as the client’s advocate by undertaking which action?

Correct answer: Noting in the client’s record that the client was not told about the risks of the surgery

Rationale: A nurse serves as a client advocate by protecting the client's right to be informed and to participate in decisions regarding care. In this scenario, the nurse should document in the client’s record that the client was not informed about the risks of the surgery. This action ensures that the issue is officially noted and can be addressed by the healthcare team. Reassuring the client that the risks are minimal is incorrect because it dismisses the client's concerns and does not address the lack of information provided. Writing a note on the client’s chart to inform the surgeon is not as effective as ensuring that the issue is officially documented in the client’s record, where it can be reviewed and addressed by the healthcare team. Informing the surgeon verbally is not as reliable as documenting the concern in the client's record, which provides a formal and lasting record for review and follow-up.

4. Which of the following medications is a serotonin antagonist that might be used to relieve nausea and vomiting?

Correct answer: ondansetron (Zofran)

Rationale: Zofran is a serotonin antagonist commonly used to relieve nausea and vomiting by blocking serotonin receptors. Metoclopramide (Reglan) acts on dopamine receptors, hydroxyzine (Vistaril) is an antihistamine, and prochlorperazine (Compazine) is a dopamine antagonist. While these medications can also be used for nausea and vomiting, they do not primarily function as serotonin antagonists like ondansetron.

5. The best definition of communication is:

Correct answer: an ongoing, interactive form of transmitting transactions.

Rationale: Communication is defined as an ongoing, interactive form of transmitting transactions. It involves a dynamic process of sending (encoding) and receiving (decoding) messages while being influenced by the experiences and perceptions of both the sender and receiver. This process is interactive and occurs within an environment, shaping individuals' self-concept, identity, and relationships. The correct answer captures the complexity and interactive nature of communication. Choice A, 'the sending and receiving of messages,' is too simplistic and does not encompass the interactive nature of communication. Choice B, 'the effect of sending verbal messages,' focuses solely on verbal communication and overlooks non-verbal forms. Choice D, 'the use of message variables to send information,' emphasizes technical aspects rather than the interactive and transactional nature of communication.

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