The patient reports an inability to taste. What is the most appropriate action for the nurse to take?
Test the hypoglossal nerve.
Evaluate the function of the Cranial nerve XI (11)
Test the glossopharyngeal nerve.
Evaluate sensory function.
The Correct Answer is D
The sense of taste is primarily mediated by the facial nerve (cranial nerve VII) and the glossopharyngeal nerve (cranial nerve IX). However, testing the function of specific cranial nerves such as the hypoglossal nerve (cranial nerve XII) or cranial nerve XI (11) is not directly related to evaluating the patient's ability to taste. Therefore, options a, b, and c would not be the most appropriate actions for the nurse to take in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
When assessing the abdomen, the nurse would expect to auscultate bowel sounds, which are the sounds made by the movement of gas and fluid through the intestines. The normal bowel sounds are characterized as high-pitched, gurgling, and occurring at a rate of 5-30 sounds per minute.
Bruits are abnormal sounds indicating turbulent blood flow and are usually assessed in other areas of the body, such as the epigastric and renal arteries, as well as in the aorta.
Friction rubs are also abnormal sounds, but they are typically heard during auscultation of the heart and lungs.
Low-pitched sonorous sounds are not typical sounds that are expected to be heard during an abdominal assessment
Correct Answer is B
Explanation
Pain is a subjective experience, and the client's report of pain should be respected and addressed promptly. If the pain medication is ordered and it has been longer than the ordered interval, the nurse should administer the medication as prescribed. In general, withholding pain medication for a client in pain is not an appropriate action.
Administering half the ordered dose of pain medication without a healthcare provider's order is also not appropriate. The nurse should follow the healthcare provider's orders for pain medication administration and titration.
It's also not appropriate to assume that the client is faking pain without adequate assessment and evidence to support such a claim. The nurse should perform a thorough pain assessment, including the location, intensity, and quality of the pain, and consider non-pharmacological interventions to help manage the pain.
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