76.76.ID: 9477077835During a neurological assessment, the nurse asks the client to close the jaws tightly, after which the nurse tries to open the closed jaws. In this technique, the nurse is assessing the motor function of the:A. Trochlear nerveB. Abducens nerveC. Trigeminal nerve CorrectD. Oculomotor nerveRationale: To test the motor function of cranial nerve V (trigeminal nerve), the nurse assesses the muscles of mastication by palpating the temporal and masseter muscles as the client clenches the teeth. The nurse tries to separate the jaws by pushing down on the client’s chin. Normally the nurse cannot separate the jaws. Testing of the trochlear, abducens, and oculomotor nerves, which are usually assessed together, involves checking the pupils for size, regularity, equality, direct and consensual light reaction, and accommodation and assessing extraocular movements through the cardinal positions of gaze.Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Recalling that the trochlear, abducens, and oculomotor nerves are usually assessed together will assist you in eliminating these options. Review: the techniques for assessing the trigeminal nerve .Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positiveoutcomes (8th ed., p. 1779). St. Louis: Saunders.Cognitive Ability: Applying
Neuro AssessmentMeet the Client: Ms. Carie DavidsonMs. Carie Davidson is an 85-year-old Caucasian. She has a history of several transient ischemic attacks (TIAs) and is being admitted to a medical unit following an episode of weakness that caused her to "pass out" at home. The nurse prepares to complete the client's admission assessment after her transfer from the emergency department.Priority Data CollectionThe nurse begins the admission assessment with the collection of priority assessment data that is immediately entered into her personal digital assistant (PDA).1. Which assessment should the nurse complete first after the client's arrival on the unit?A) Sensory function. INCORRECT Sensory function is an important component of a neurological assessment, but is not the highest priority assessment at this time.B) Orientation. INCORRECT Orientation is an important component of a neurological assessment, but another assessment is of higher priority.C) Speech patterns. INCORRECT Speech patterns are an important component of a neurological assessment, but are not the highest priority assessment at this time.D) Level of consciousness. CORRECT In planning care, a top priority is client safety. Assessment of the client's level of consciousness is essential to determine the care needed to ensure client safety.Correct Answer(s):D2. Based on Ms. Davidson's recent history of loss of consciousness and falling, what additional assessment takespriority?