LCCC NURS 120 Test 1: Study Guide
Questions With All Correct & Verified
Answers
QSEN competencies Correct answer-Patient-Centered Care
Teamwork and Collaboration
Evidence-Based Practice
Quality Improvement
Safety
Informatics
OLDCART & ICE Correct answer-O- onset, L- location, D- duration, C- characteristics, A- aggravating
factors, R-relieving factors, T-treatment, and I- impact on ADL's, C- coping strategies, and E-
emotional response
SBAR Correct answer-S: Situation
B: Background
A: Assessment
R: Recommendation
Maslow's Hierarchy of Needs Correct answer-physiological, safety, love/belonging, esteem, self-
actualization
Braden Scale for Predicting Pressure Sore Risk Correct answer-sensory perception, moisture,
activity, mobility, nutrition, friction and shear
ADPIE - Nursing Process Correct answer-Assessment
Diagnosis
Planning
Implementation
Evaluation
Cranial Nerve I: Olfactory Correct answer-sensory, smell
Cranial Nerve II: Optic Correct answer--Function: sensory - carries impulse for vision
-Testing procedure: eye chart testing, visual field testing
Cranial Nerve III: Oculomotor Correct answer---Function: motor - fibers to the superior, inferior
and medial rectus muscles of the eye and to the smooth muscle controlling lens shape. Medial and
vertical eye movements; sensory - proprioception of the eye
-Testing procedure: pupil sizes are compared for shape and equality, pupillary reflex is tested; visual
tracking is tested
Cranial Nerve IV: Trochlear Correct answer--Function: proprioceptor and motor fibers for superior
oblique muscle of the eye. Downward and inward eye movements.
-Testing procedure: tested with cranial nerve III relative to following moving objects
, Cranial Nerve V: Trigeminal Correct answer--Function: motor and sensory for face, conducts
sensory impulses from mouth, nose, eyes; motor fibers for muscles of mastication. Control of jaw
movements
-Testing procedure: pain, touch, and temperature are tested with proper stimulus; corneal reflex
tested with a wisp of cotton; person is asked to move jaw through full ranges of motion
Cranial Nerve VI: Abducens Correct answer--Function: motor and proprioceptor fibers to/from
lateral rectus muscle. Lateral eye movements
-Testing procedure: tested in conjunction with cranial nerve III relative to moving eye laterally
Cranial Nerve VII: Facial Correct answer-mixed (sensory and motor) sensory fibers to taste buds
and anterior 2/3 tongue; motor fibers to muscles of facial expression and to salivary glands
-Testing procedure: check symmetry of face, ask person to attempt various facial expressions; sweet,
salty, sour, and bitter substances are applied to tongue to test tasting ability
Cranial Nerve VIII: Vestibulocochlear Correct answer-hearing and balance
Cranial Nerve IX: Glossopharyngeal Correct answer--Function: motor fibers for pharynx and
salivary glands; sensory fibers for pharynx and posterior tongue. Taste sensation for sweet, bitter and
sour
-Testing procedure: gag and swallow reflexes are checked; posterior one third of tongue is tested for
taste
Cranial Nerve X: Vagus Correct answer--Function: sensory/motor impulses for larynx and pharynx;
parasympathetic motor fibers supply smooth muscles of abdominal organs; sensory impulses from
viscera
-Testing procedure: tested in conjunction with cranial nerve IX
Cranial Nerve XI: Accessory Correct answer-Function: Motor - to sternocledomastoid and
trapezius; Foramen: foramen magnum, jugular foramen; Consequence ot Loss: difficulty elevating
scapula or rotating neck
Cranial Nerve XII: Hypoglossal Correct answer--Function: motor/sensory fibers to/from tongue.
Movement of tongue
-Testing procedure: ask person to stick out tongue, positional abnormalities are noted
comfort nursing implications Correct answer-assess related symptoms of increased pulse rate,
respirations,blood pressure, restlessness, anxiety, diaphoresis;; client reports of discomfort.
Anticipate need for additional assessments, medications for pain relief, diversional therapies.
Health Care Delivery Correct answer-The provision of preventive, treatment, or rehabilitative
health services, from short term to long term, to individuals as well as groups of people, by individual
practitioners, institutions, or public health agencies.
culture-nursing Correct answer-Respect a patient's cultural beliefs/practices—if the cultural belief
or the traditional healer's advice does not cause harm to the patient, then the RN should support the
practice. If
a cultural practice has an adverse effect on a patient's health, then the NP needs to explain to the
patient in a sensitive manner the reason for not following the practice.
Questions With All Correct & Verified
Answers
QSEN competencies Correct answer-Patient-Centered Care
Teamwork and Collaboration
Evidence-Based Practice
Quality Improvement
Safety
Informatics
OLDCART & ICE Correct answer-O- onset, L- location, D- duration, C- characteristics, A- aggravating
factors, R-relieving factors, T-treatment, and I- impact on ADL's, C- coping strategies, and E-
emotional response
SBAR Correct answer-S: Situation
B: Background
A: Assessment
R: Recommendation
Maslow's Hierarchy of Needs Correct answer-physiological, safety, love/belonging, esteem, self-
actualization
Braden Scale for Predicting Pressure Sore Risk Correct answer-sensory perception, moisture,
activity, mobility, nutrition, friction and shear
ADPIE - Nursing Process Correct answer-Assessment
Diagnosis
Planning
Implementation
Evaluation
Cranial Nerve I: Olfactory Correct answer-sensory, smell
Cranial Nerve II: Optic Correct answer--Function: sensory - carries impulse for vision
-Testing procedure: eye chart testing, visual field testing
Cranial Nerve III: Oculomotor Correct answer---Function: motor - fibers to the superior, inferior
and medial rectus muscles of the eye and to the smooth muscle controlling lens shape. Medial and
vertical eye movements; sensory - proprioception of the eye
-Testing procedure: pupil sizes are compared for shape and equality, pupillary reflex is tested; visual
tracking is tested
Cranial Nerve IV: Trochlear Correct answer--Function: proprioceptor and motor fibers for superior
oblique muscle of the eye. Downward and inward eye movements.
-Testing procedure: tested with cranial nerve III relative to following moving objects
, Cranial Nerve V: Trigeminal Correct answer--Function: motor and sensory for face, conducts
sensory impulses from mouth, nose, eyes; motor fibers for muscles of mastication. Control of jaw
movements
-Testing procedure: pain, touch, and temperature are tested with proper stimulus; corneal reflex
tested with a wisp of cotton; person is asked to move jaw through full ranges of motion
Cranial Nerve VI: Abducens Correct answer--Function: motor and proprioceptor fibers to/from
lateral rectus muscle. Lateral eye movements
-Testing procedure: tested in conjunction with cranial nerve III relative to moving eye laterally
Cranial Nerve VII: Facial Correct answer-mixed (sensory and motor) sensory fibers to taste buds
and anterior 2/3 tongue; motor fibers to muscles of facial expression and to salivary glands
-Testing procedure: check symmetry of face, ask person to attempt various facial expressions; sweet,
salty, sour, and bitter substances are applied to tongue to test tasting ability
Cranial Nerve VIII: Vestibulocochlear Correct answer-hearing and balance
Cranial Nerve IX: Glossopharyngeal Correct answer--Function: motor fibers for pharynx and
salivary glands; sensory fibers for pharynx and posterior tongue. Taste sensation for sweet, bitter and
sour
-Testing procedure: gag and swallow reflexes are checked; posterior one third of tongue is tested for
taste
Cranial Nerve X: Vagus Correct answer--Function: sensory/motor impulses for larynx and pharynx;
parasympathetic motor fibers supply smooth muscles of abdominal organs; sensory impulses from
viscera
-Testing procedure: tested in conjunction with cranial nerve IX
Cranial Nerve XI: Accessory Correct answer-Function: Motor - to sternocledomastoid and
trapezius; Foramen: foramen magnum, jugular foramen; Consequence ot Loss: difficulty elevating
scapula or rotating neck
Cranial Nerve XII: Hypoglossal Correct answer--Function: motor/sensory fibers to/from tongue.
Movement of tongue
-Testing procedure: ask person to stick out tongue, positional abnormalities are noted
comfort nursing implications Correct answer-assess related symptoms of increased pulse rate,
respirations,blood pressure, restlessness, anxiety, diaphoresis;; client reports of discomfort.
Anticipate need for additional assessments, medications for pain relief, diversional therapies.
Health Care Delivery Correct answer-The provision of preventive, treatment, or rehabilitative
health services, from short term to long term, to individuals as well as groups of people, by individual
practitioners, institutions, or public health agencies.
culture-nursing Correct answer-Respect a patient's cultural beliefs/practices—if the cultural belief
or the traditional healer's advice does not cause harm to the patient, then the RN should support the
practice. If
a cultural practice has an adverse effect on a patient's health, then the NP needs to explain to the
patient in a sensitive manner the reason for not following the practice.
