A nurse is performing a neurological assessment for a client with head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve II?
Instruct the client to look up and down without moving his head.
Ask the client to shrug his shoulders against passive resistance.
Observe the client's ability to smile and frown.
Have the client stand with eyes his closed and touch his nose.
The Correct Answer is A
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Complete a vascular assessment: Although meningococcal meningitis can lead to complications such as septicemia, which affects vascular status, assessing cranial nerves is more immediately pertinent. Identifying neurological deficits can provide crucial information about the extent and location of meningitis-related brain involvement.
B. Assess the cranial nerves: This is the correct action to initiate next. Meningococcal meningitis can affect the central nervous system, leading to cranial nerve involvement. Assessing the cranial nerves helps to identify any neurological deficits early, which is crucial for guiding treatment and monitoring progression.
C. Decrease environmental stimuli: While this is important for managing a patient with meningitis to prevent further neurological irritation, it is not as immediate a priority as assessing cranial nerve function to detect any neurological impairment.
D. Administer an antipyretic: Fever management is important, but it is not the next immediate priority after initiating droplet precautions. Assessing cranial nerves provides vital information about the patient's neurological status, which directly impacts immediate clinical decisions.
Correct Answer is D
Explanation
A. Incorrect. Complete darkness at night can increase confusion and agitation in clients with Alzheimer's disease. The room should have adequate lighting and a night light to help orient the client and prevent falls.
B. Incorrect. Suction equipment is not necessary for clients with Alzheimer's disease unless they have respiratory problems or difficulty swallowing. Suction equipment can be noisy and frightening for clients with cognitive impairment and should be avoided unless indicated.
C. Incorrect. A walker or cane may be helpful for clients with Alzheimer's disease who have mobility issues, but it is not an essential item to include in the room. A walker or cane can also pose a tripping hazard or be used as a weapon by agitated clients.
D. Correct. Clocks, calendar, family photos are appropriate items to include in the room of a client with Alzheimer's disease. They can help the client maintain orientation to time, place, and person, and provide comfort and familiarity.
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