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 C
Explanation
When a patient is admitted with a complaint of chest pain, the priority assessment would be to determine whether the patient is experiencing an acute cardiac event, such as a heart attack. This would involve a comprehensive assessment that includes obtaining the patient's medical history, vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation), performing a physical exam, and obtaining an electrocardiogram (ECG).
Other important factors to assess include the location and nature of the pain, any associated symptoms (such as shortness of breath or diaphoresis), the patient's current medications and medical history (including any history of heart disease or risk factors), and any recent procedures or interventions that may have led to the current presentation.
Prompt assessment and intervention are crucial in managing a patient with chest pain, as timely treatment can help to minimize damage to the heart muscle and prevent further complications. Therefore, any signs of an acute cardiac event should be immediately reported to the healthcare provider in charge, and appropriate interventions should be initiated promptly.
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
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