NUR1020C Term 1 Exam 2 UPDATED
QUESTIONS AND CORRECT ANSWERS
List the cranial nerves in order - CORRECT ANSWER I Olfactory (Smell)
II Optic (Vision)
III Oculomotor (Moves eyelid and eyeball and adjusts the pupil and lens of the eye)
IV Trochlear (Moves eyeballs)
V Trigeminal (Facial muscles incl. chewing; Facial sensations)
VI Abducens (Moves eyeballs)
VII Facial (Taste, tears, saliva, facial expressions)
VIII Vestibulocochlear (Auditory/balance)
IX Glossopharyngeal (Swallowing, speech)
X Vagus (swalling/coughing/voice production)
XI Accessory (Moving head & shoulders)
XII Hypoglossal (Tongue muscles - speech & swallowing)
Cranial Nerve I - CORRECT ANSWER Olfactory (Smell) - SENSORY
Cranial Nerve II - CORRECT ANSWER Optic (Vision) - SENSORY
Cranial Nerve III - CORRECT ANSWER Oculomotor (Moves eyelid and eyeball and
adjusts the pupil and lens of the eye) - MOTOR
Cranial Nerve IV - CORRECT ANSWER Trochlear (Moves eyeballs) - MOTOR
Cranial Nerve V - CORRECT ANSWER Trigeminal (Facial muscles incl. chewing;
Facial sensations) - SENSORY/MOTOR
Cranial Nerve VI - CORRECT ANSWER Abducens (Moves eyeballs) - MOTOR
,Cranial Nerve VII - CORRECT ANSWER Facial (Taste, tears, saliva, facial
expressions) - SENSORY/MOTOR
Cranial Nerve VIII - CORRECT ANSWER Vestibulocochlear (Auditory/balance) -
SENSORY
Cranial Nerve IX - CORRECT ANSWER Glossopharyngeal (Swallowing, speech) -
SENSORY/MOTOR
Cranial Nerve X - CORRECT ANSWER Vagus (swalling/coughing/voice production) -
SENSORY/MOTOR
Cranial Nerve XI - CORRECT ANSWER Accessory (Moving head & shoulders) -
MOTOR
Cranial Nerve XII - CORRECT ANSWER Hypoglossal (Tongue muscles - speech &
swallowing) - MOTOR
How to test cranial nerve III, IV, VI - CORRECT ANSWER Have pt follow penlight
without moving head
How to test cranial nerve V - CORRECT ANSWER Cotton on face/ testing TMJ
(Temporomandibular joint disorder) - trying to pull jaw down
How to test cranial nerve VII - CORRECT ANSWER Raise eyebrows, closing eyes
tight, show teeth, smile, frown, puff cheeks and let air out - look for symmetry
How to test cranial nerve XI - CORRECT ANSWER ROM - head forward, back, side
to side. Shrug shoulders. Then with resistance.
,What is PERRLA - CORRECT ANSWER Pupils equal, Round, React to light, and
Accommodation
Examine PERRLA by - CORRECT ANSWER Asking the patient to stare off and focus
on something and bring pen light from side and watch pupils react.
Nursing Process - CORRECT ANSWER critical thinking five-step process
Involves looking at the whole patient at all times
Personalizes the patient
It provides a "road map" that ensures good nursing care & improves patient outcomes
ADPIE - CORRECT ANSWER Assessment - Gather information about the patient's
condition
Diagnosis - Identify the patient's problem
Planning - Set goals of care and desired outcomes and identify appropriate nursing action
Implementation - Preform the nursing actions identified in planning
Evaluation - Determine if goals and expected outcomes are achieved
Types of assessments - CORRECT ANSWER - the patient-centered interview during a
nursing health history.
- a physical examination.
- the periodic assessments you make during rounding or administering care.
- Cue (information that you obtain through use of the senses)
- Inference (your judgment or interpretation of these cues)
subjective data - CORRECT ANSWER patient's verbal descriptions of their health
problems
ex: Mr. Lawson's self-report of pain at the area where his incision slightly separated
, objective data - CORRECT ANSWER observations or measurements of a patient's
health status
ex: vital signs; describing an observed behavior; condition of a surgical wound
The second step in the nursing process can be started after... - CORRECT
ANSWER interpreting and validating assessment data, which ensures collection of
complete database.
Data documentation should be ________ and ______ and will be used for _______ ? -
CORRECT ANSWER clear and concise (appropriate terminology)
baseline for care
Formulating a nursing diagnosis statement consists of... - CORRECT
ANSWER Identifying the correct diagnostic label with associated defining
characteristics or risk factors and a related factor.
What is the difference between a medical diagnosis and a nursing diagnosis? - CORRECT
ANSWER medical diagnosis: identification of a disease condition based on a specific
evaluation of physical signs and symptoms, a patient's medical history, and the results of
diagnostic tests and procedures
nursing diagnosis: a clinical judgment concerning a human response to health condition/life
processes, vulnerability for that response by an individual, family, or community that a nurse
is licensed and competent to treat
What does NANDA nursing diagnosis include? - CORRECT ANSWER problem
focused
risk (physiological, environmental, psychosocial)
health promotion
QUESTIONS AND CORRECT ANSWERS
List the cranial nerves in order - CORRECT ANSWER I Olfactory (Smell)
II Optic (Vision)
III Oculomotor (Moves eyelid and eyeball and adjusts the pupil and lens of the eye)
IV Trochlear (Moves eyeballs)
V Trigeminal (Facial muscles incl. chewing; Facial sensations)
VI Abducens (Moves eyeballs)
VII Facial (Taste, tears, saliva, facial expressions)
VIII Vestibulocochlear (Auditory/balance)
IX Glossopharyngeal (Swallowing, speech)
X Vagus (swalling/coughing/voice production)
XI Accessory (Moving head & shoulders)
XII Hypoglossal (Tongue muscles - speech & swallowing)
Cranial Nerve I - CORRECT ANSWER Olfactory (Smell) - SENSORY
Cranial Nerve II - CORRECT ANSWER Optic (Vision) - SENSORY
Cranial Nerve III - CORRECT ANSWER Oculomotor (Moves eyelid and eyeball and
adjusts the pupil and lens of the eye) - MOTOR
Cranial Nerve IV - CORRECT ANSWER Trochlear (Moves eyeballs) - MOTOR
Cranial Nerve V - CORRECT ANSWER Trigeminal (Facial muscles incl. chewing;
Facial sensations) - SENSORY/MOTOR
Cranial Nerve VI - CORRECT ANSWER Abducens (Moves eyeballs) - MOTOR
,Cranial Nerve VII - CORRECT ANSWER Facial (Taste, tears, saliva, facial
expressions) - SENSORY/MOTOR
Cranial Nerve VIII - CORRECT ANSWER Vestibulocochlear (Auditory/balance) -
SENSORY
Cranial Nerve IX - CORRECT ANSWER Glossopharyngeal (Swallowing, speech) -
SENSORY/MOTOR
Cranial Nerve X - CORRECT ANSWER Vagus (swalling/coughing/voice production) -
SENSORY/MOTOR
Cranial Nerve XI - CORRECT ANSWER Accessory (Moving head & shoulders) -
MOTOR
Cranial Nerve XII - CORRECT ANSWER Hypoglossal (Tongue muscles - speech &
swallowing) - MOTOR
How to test cranial nerve III, IV, VI - CORRECT ANSWER Have pt follow penlight
without moving head
How to test cranial nerve V - CORRECT ANSWER Cotton on face/ testing TMJ
(Temporomandibular joint disorder) - trying to pull jaw down
How to test cranial nerve VII - CORRECT ANSWER Raise eyebrows, closing eyes
tight, show teeth, smile, frown, puff cheeks and let air out - look for symmetry
How to test cranial nerve XI - CORRECT ANSWER ROM - head forward, back, side
to side. Shrug shoulders. Then with resistance.
,What is PERRLA - CORRECT ANSWER Pupils equal, Round, React to light, and
Accommodation
Examine PERRLA by - CORRECT ANSWER Asking the patient to stare off and focus
on something and bring pen light from side and watch pupils react.
Nursing Process - CORRECT ANSWER critical thinking five-step process
Involves looking at the whole patient at all times
Personalizes the patient
It provides a "road map" that ensures good nursing care & improves patient outcomes
ADPIE - CORRECT ANSWER Assessment - Gather information about the patient's
condition
Diagnosis - Identify the patient's problem
Planning - Set goals of care and desired outcomes and identify appropriate nursing action
Implementation - Preform the nursing actions identified in planning
Evaluation - Determine if goals and expected outcomes are achieved
Types of assessments - CORRECT ANSWER - the patient-centered interview during a
nursing health history.
- a physical examination.
- the periodic assessments you make during rounding or administering care.
- Cue (information that you obtain through use of the senses)
- Inference (your judgment or interpretation of these cues)
subjective data - CORRECT ANSWER patient's verbal descriptions of their health
problems
ex: Mr. Lawson's self-report of pain at the area where his incision slightly separated
, objective data - CORRECT ANSWER observations or measurements of a patient's
health status
ex: vital signs; describing an observed behavior; condition of a surgical wound
The second step in the nursing process can be started after... - CORRECT
ANSWER interpreting and validating assessment data, which ensures collection of
complete database.
Data documentation should be ________ and ______ and will be used for _______ ? -
CORRECT ANSWER clear and concise (appropriate terminology)
baseline for care
Formulating a nursing diagnosis statement consists of... - CORRECT
ANSWER Identifying the correct diagnostic label with associated defining
characteristics or risk factors and a related factor.
What is the difference between a medical diagnosis and a nursing diagnosis? - CORRECT
ANSWER medical diagnosis: identification of a disease condition based on a specific
evaluation of physical signs and symptoms, a patient's medical history, and the results of
diagnostic tests and procedures
nursing diagnosis: a clinical judgment concerning a human response to health condition/life
processes, vulnerability for that response by an individual, family, or community that a nurse
is licensed and competent to treat
What does NANDA nursing diagnosis include? - CORRECT ANSWER problem
focused
risk (physiological, environmental, psychosocial)
health promotion
