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. 3.97.ID: 383733709During a neurological assessment, the nurse asks the client to puff out both cheeks. Which cranial nerve is the nurse assessing? A.Vagus B.Facial CorrectC.Abducens D.Oculomotor Rationale: Assessment of cranial nerve VII (facial nerve) involves noting mobility and symmetry as the client smiles, frowns, closes the eyes tightly (against the nurse’s attempt to open them), lifts the eyebrows, shows the teeth, and puffs out the cheeks. Cranial nerve IX
(glossopharyngeal nerve) and cranial nerve X (vagus nerve) are tested together. Testing the motor function of these nerves entails depressing the client’s tongue with a tongue blade and noting pharyngeal movement as the client says “ah” and touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex. Testing of the abducens, oculomotor, and trochlear nerves, which are usually assessed together, involves checking the pupils for size, regularity, equality, direct and consensual light reaction, and accommodation and testing extraocular movements through the cardinal positions of gaze.98.ID: 383733705A client complains that he feels as though his ear is blocked and tells the nurse that he has a history of cerumen impaction in the external ear. The nurse, inspecting the ears for cerumen impaction, checks for: E.Redness and swelling of the tympanic membrane F.An external auditory canal that is longer than normal G.The presence of edema in the external auditory canal H.A yellowish or brownish waxy material in the external auditory canal CorrectRationale: Cerumen (ear wax) is a yellowish or brownish waxy secretion produced by vestigial apocrine sweat glands in the external ear canal. It becomes impacted because of the narrow tortuous canal or as a result of poor cleaning methods. Cerumen may partially obscure the eardrum or totally occlude the ear canal. Even when the canal is 90% to 95% blocked, hearing isnormal, but when the last 5% to 10% becomes occluded (e.g., when cerumen expands after the client swims or showers), the client experiences sudden hearing loss and a feeling of fullness in the ear. Redness and swelling of the tympanic membrane, edema in the external auditory canal, and an external auditory canal that is longer than normal are not descriptions of cerumen.