A nurse is preparing to reposition a patient.
Which of the following actions should the nurse take first?

Elevate the height of the patient’s bed

Tighten their abdominal muscles

Position their feet in line with their shoulders

Pivot their feet in the direction of the move

Answer and Explanation

The Correct Answer is A

Choice A rationale
Before repositioning a patient, the nurse should first elevate the height of the patient’s bed. This allows the nurse to work at a comfortable height and reduces the risk of injury.
Choice B rationale
While tightening the abdominal muscles can help with lifting and moving, it is not the first action the nurse should take when preparing to reposition a patient.
Choice C rationale
Positioning the feet in line with the shoulders can provide a stable base of support when moving or lifting. However, this is not the first action the nurse should take when preparing to reposition a patient.
Choice D rationale
Pivoting the feet in the direction of the move can help with turning and moving. However, this is not the first action the nurse should take when preparing to reposition a patient.

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Correct Answer is C

Explanation

Choice A rationale
Checking the patient’s visual acuity using a Snellen chart is used to assess cranial nerve II (Optic), not cranial nerve XI (Spinal Accessory)3.
Choice B rationale
Whispering in one of the patient’s ears while blocking the other is a method used to assess cranial nerve VIII (Vestibulocochlear), not cranial nerve XI4.
Choice C rationale
Observing the patient’s ability to turn their head from side to side is a correct method to assess cranial nerve XI. This nerve innervates the sternocleidomastoid and trapezius muscles, which are responsible for turning the head and shrugging the shoulders respectively.
Choice D rationale
Asking the patient to identify specific smells is used to assess cranial nerve I (Olfactory), not cranial nerve XI3.

A. “I can take analgesics every four hours for pain.”. B. “I will chew on the affected side to prevent swallowing issues.”. C. “I can still brush my teeth with no issues.”. D. “I will apply this protective eye shield before going to bed.”. .

Correct Answer is B

Explanation

Choice A rationale
Analgesics can be used to manage pain associated with Bell’s palsy. Therefore, this statement does not indicate a need for further education.
Choice B rationale
This is the correct answer. Chewing on the affected side can actually exacerbate swallowing issues. Therefore, this statement indicates a need for further education.
Choice C rationale
Brushing teeth should not be affected by Bell’s palsy. Therefore, this statement does not indicate a need for further education.
Choice D rationale
Applying a protective eye shield before going to bed is a recommended practice for patients with Bell’s palsy. This helps to protect the eye from injury and keep it moist, as Bell’s palsy can cause difficulty in blinking or closing the eye.

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A nurse is preparing to reposition a patient. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is getting ready to conduct a cranial nerve examination on a patient. What steps should the nurse take to examine cranial nerve XI (Spinal Accessory)?

Correct Answer is C

Explanation

In the context of outpatient care for a client diagnosed with Bell’s palsy, which of the following statements, if made by the client, would indicate the need for further education?

Correct Answer is B

Explanation

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A nurse is preparing to reposition a patient.
Which of the following actions should the nurse take first?