The nurse is assessing a patient's cranial nerve function and notes that the patient has absent corneal reflex on one side. What is the most likely cause of this finding?

Correct Answer: A

Rationale: The correct answer is A: Unilateral facial nerve paralysis. The corneal reflex is mediated by the trigeminal nerve (cranial nerve V) afferent limb and facial nerve (cranial nerve VII) efferent limb. Absent corneal reflex on one side indicates a dysfunction in the facial nerve, which controls the blinking reflex in response to corneal stimulation. Trigeminal nerve dysfunction (choice B) would present with sensory deficits, not specifically affecting the corneal reflex. Upper motor neuron lesion (choice C) would typically present with bilateral findings, and lower motor neuron lesion (choice D) would affect the facial muscles directly, not the corneal reflex.

Correct Answer: C

Rationale: Hypothyroidism, is correct because an underactive thyroid reduces metabolism, lowering heat production and thus body temperature (e.g., below 97°F). Cerebral palsy, affects movement, not thermoregulation directly. Infection, typically raises temperature (fever). Fever, by definition increases temperature. Hypothyroidism slows cellular activity, impairing the bodys ability to maintain normal temperature, often causing cold intolerance. Clinical evidence links it to subnormal readings, unlike the other options, which either elevate temperature or have no direct effect. Thus, C is the accurate choice based on endocrine physiology.

Correct Answer: A

Rationale: A blood pressure of 130/90 mmHg is mildly elevated (prehypertension or Stage 1 hypertension). Follow-up measurements are recommended to confirm if its persistent, as a single reading isnt diagnostic. Immediate treatment is premature without trends. Assuming anxiety dismisses the need for monitoring, which is risky. Dietary changes may help long-term but arent the first step. Choice A aligns with guidelines (e.g., AHA) for tracking blood pressure over time to establish a pattern, ensuring proper management.

Correct Answer: B

Rationale: Doppler ultrasound enhances BP measurement in low-flow states. Standing isn't required. Centering the cuff over the artery ensures accuracy, a key guideline. Mercury manometers aren't Doppler-specific. Doppler tip placement is technique, not a guideline. Choice B is correct, aligning with proper cuff positioning per Doppler protocols.

Correct Answer: A

Rationale: Older adults often have lower baseline temperatures (e.g., 96.8°F) due to slower metabolism; is normal. Too high or infection doesn't fit without symptoms. Intervention is unnecessary. Choice A is correct, per geriatric nursing norms.