Chapter 26 Health & Physical Assessment In Nursing 3rd Edition by Donita T D'Amico

Chapter 26 Health & Physical Assessment In Nursing 3rd Edition by Donita T D’Amico

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Question 1

Type: MCMA

The nurse is reviewing the cranial nerves prior to a PRN shift on a neurological unit. Upon the review, the nurse notes that some of the nerves are exclusively sensory nerves. Which cranial nerves belong to this group?

Standard Text: Select all that apply.

1. Olfactory nerve (cranial nerve I).
2. Optic nerve (cranial nerve II).
3. Trochlear nerve (cranial nerve IV).
4. Trigeminal nerve (cranial nerve V).
5. Facial nerve (cranial nerve VII).

Correct Answer: 1, 2

Rationale 1: The olfactory nerve is a sensory nerve and is responsible for the sense of smell. The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. The optic nerve is a sensory nerve responsible for vision.

Rationale 2: The optic nerve is a sensory nerve responsible for vision. The cranial nerves may be classified by function. The nerves may be sensory, motor or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. The olfactory nerve is a sensory nerve and is responsible for the sense of smell.

Rationale 3: The trochlear nerve is a motor nerve responsible for eye movement. The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities.

Rationale 4: The trigeminal nerve is a mixed nerve is responsible for sensory impulses from the lower eyelid, nasal cavity and palate. Motor actions of the trigeminal nerve involve teeth clenching and movement of the mandible. The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities.

Rationale 5: The facial nerve is a mixed nerve responsible for taste, facial movements, and the production of tears and salivary stimulation. The cranial nerves may be classified by function. The nerves may be sensory, motor or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities.

Global Rationale: The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. The olfactory nerve is a sensory nerve and is responsible for the sense of smell. The optic nerve is a sensory nerve responsible for vision. Mixed nerves are able to receive sensory information and perform physical activities. The trochlear nerve is a motor nerve responsible for eye movement. The trigeminal nerve is a mixed nerve is responsible for sensory impulses from the lower eyelid, nasal cavity, and palate. Motor actions of the trigeminal nerve involve teeth clenching and movement of the mandible. The facial nerve is a mixed nerve responsible for taste, facial movements, and the production of tears and salivary stimulation.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26.1: Describe the anatomy and physiology of the neurologic system.

MNL Learning Outcome: 11.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.

Page Number: p. 749

 

Question 2

Type: HOTSPOT

The nurse is caring for a client having problems with emotional appropriateness as a result of a brain injury. Based on this data, which area of the brain has been damaged?

D

C

B

A

 

1. A.
2. B.
3. C.
4. D.

Correct Answer: 1

Rationale: The frontal lobe of the cerebrum is responsible for the control of emotions.

Global Rationale: The frontal lobe of the cerebrum is responsible for the control of emotions.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26.1: Describe the anatomy and physiology of the neurologic system.

MNL Learning Outcome: 11.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.

Page Number: p. 746

 

Question 3

Type: HOTSPOT

The nurse is caring for a client with a traumatic brain injury (TBI). The client begins to experience bradycardia. Which area of the brain is likely responsible for the changes in heart rate?

D

C

B

A

1. A.
2. B.
3. C.
4. D.

Correct Answer: 4

Rationale: The brain stem is responsible for control of the vital signs.

Global Rationale: The brain stem is responsible for control of the vital signs.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.

AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.

NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26.1: Describe the anatomy and physiology of the neurologic system.

MNL Learning Outcome: 11.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.

Page Number: p. 747