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)?

Deviation of the tongue from midline

Loss of peripheral vision

Disequilibrium with movement

Inability to smell

Answer and Explanation

The Correct Answer is C

The nurse should expect disequilibrium with movement if the client has impaired function of the vestibulocochlear nerve, as this nerve is responsible for hearing and balance. Deviation of the tongue from midline indicates impairment of the hypoglossal nerve (cranial nerve XII), loss of peripheral vision indicates impairment of the optic nerve (cranial nerve II), and inability to smell indicates impairment of the olfactory nerve (cranial nerve I).

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Correct Answer is A

Explanation

Applying an ice pack to the client's knee can help reduce inflammation, swelling, and pain after a total knee arthroplasty. The nurse should avoid placing pillows under the client's knee, as this can cause flexion contractures and impair mobility and healing. Massaging or manipulating the incision site can increase pain and risk of infection or bleeding. Range-of-motion exercises are important for recovery, but they should be done with caution and under supervision, not when the client is experiencing severe pain.

A. Serum albumin level 3.9 g/dL B. Calcium level 11.5 mg/dL C. Output 200 mL more than intake over the past 12 hr D. Fasting blood glucose level 105 mg/dL.

Correct Answer is B

Explanation

A high calcium level (hypercalcemia) can indicate complications of TPN, such as bone demineralization, renal calculi, or metabolic alkalosis. The nurse should notify the provider of this finding and expect to adjust the TPN formula or administer fluids and diuretics to lower the calcium level. The other options are within normal or expected ranges for a client receiving TPN.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level of 6 on a pain scale of 0 to 10. Which of the following interventions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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