A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?

Inability to smell

Loss of peripheral vision

Disequilibrium with movement

Deviation of the tongue from midline

Answer and Explanation

The Correct Answer is C

C. The vestibulocochlear nerve is responsible for both the vestibular function and the cochlear function. Impaired function of the vestibulocochlear nerve could result in symptoms related to vestibular dysfunction, such as disequilibrium (feeling unsteady or off balance) especially with movement.

A. The olfactory nerve (cranial nerve I) is responsible for the sense of smell.
B. Loss of peripheral vision is typically associated with impairment of the optic nerve (cranial nerve II), which is responsible for vision.
D. Deviation of the tongue occurs in injury to the hypoglossal nerve.

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Correct Answer is D

Explanation

Thawed FFP should be administered promptly. It can be stored at 1 to 6 degrees Celsius for up to 24 hours if not used immediately. However, it is best to administer it as soon as possible after thawing.
A. FFP should be administered through a larger-bore intravenous catheter (typically 18-20 gauge) to prevent clotting or clogging of the line.
B. The recommended infusion time for FFP is approximately 30 minutes to 1 hour. Rapid infusion helps maintain clotting factor activity.
C. FFP is specifically used to manage bleeding due to coagulopathy. If the client is actively bleeding, timely FFP administration is crucial.

A. Remains 3 feet away from the client B. Wears an N95 mask when providing wound care C. Disposes of isolation gown outside of the client's room D. Wears clean gloves when caring for the client

Correct Answer is D

Explanation

MRSA is spread through direct contact with infected persons or infectious droplets.
A. Keeping a safe distance is important but 3 feet away is not enough precaution.
B. MRSA is not airborne and hence not prevented through wearing of masks
C. The isolation gowns should be disposed in designated areas to prevent the spread of the infection.

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A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?

Nursing Test Bank

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