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)?
Disequilibrium with movement
Deviation of the tongue from midline
Loss of peripheral vision
mobility to smell
The Correct Answer is A
Choice A reason:
Disequilibrium with movement is correct. The vestibulocochlear nerve (cranial nerve VIII) is responsible for both hearing (cochlear component) and balance (vestibular component). Impaired function of this nerve can result in problems with equilibrium and balance, leading to symptoms such as disequilibrium or vertigo (a sensation of spinning or whirling), especially with movement.
Choice B Reason:
Deviation of the tongue from midline is incorrect. This is related to cranial nerve XII (hypoglossal nerve) and its role in tongue movement and control.
Choice C Reason:
Loss of peripheral vision is incorrect. This is related to cranial nerve II (optic nerve) and its role in vision.
Choice D Reason:
Inability to smell is incorrect. This is related to cranial nerve I (olfactory nerve) and its role in the sense of smell.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Measuring the client's blood pressure is appropriate. Assessing the client's blood pressure is a crucial initial step to determine the client's perfusion status and the impact of the bradycardia on their circulation. Sinus bradycardia can result in decreased cardiac output and compromised blood flow to various organs. Measuring the blood pressure helps the nurse evaluate the severity of the bradycardia and its potential effects on the client's overall condition.
Choice B Reason:
Administering atropine to the client is inappropriate. Atropine is a medication that can be used to increase heart rate in bradycardic situations. However, assessing blood pressure comes first to ensure that the blood pressure isn't critically low before administering medications.
Choice C reason:
Initiating IV fluid therapy for the client is inappropriate. Fluid therapy might be necessary to improve perfusion in certain cases, but assessing blood pressure should be done first to guide treatment decisions.
Choice D Reason:
Preparing the client for temporary pacing is inappropriate Temporary pacing might be required in severe cases of bradycardia, but again, assessing blood pressure takes priority to determine the urgency of intervention.
Correct Answer is A
Explanation
Choice A Reason:
Capillary blood glucose level 164 mg/dl is appropriate. A capillary blood glucose level of 164 mg/dl is above the target range for blood glucose control. In a client receiving total parenteral nutrition (TPN), it's essential to monitor blood glucose levels closely, as hyperglycaemia can lead to complications. The nurse should intervene by notifying the healthcare provider and following the prescribed protocols for managing elevated blood glucose levels in a client with acute pancreatitis receiving TPN.
Choice B Reason:
Crackles in bilateral lower lobes is inappropriate. Crackles in the lungs could be indicative of fluid accumulation or inflammation, which can occur in various conditions. While it should be monitored, it may not require immediate intervention related to the TPN.
Choice C Reason:
WBC count 13,000/mm is inappropriate-. An elevated white blood cell count could be related to the acute pancreatitis itself or other factors. It might require further assessment and monitoring but may not be directly related to the TPN.
Choice D Reason:
Right upper quadrant pain is inappropriate- The client's right upper quadrant pain might be related to the acute pancreatitis or another cause, but it does not specifically indicate a need to intervene with the TPN at this moment.
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