A nurse is collecting data about cranial nerve function from an adult client. Which of the following images depicts the method the nurse should use to check the function of the hypoglossal cranial nerve (XII)?
Image A
 |
B.
C.
Image B
Image C
Image D
Image A
Image B
Image C
Image D
The Correct Answer is A
A. The hypoglossal nerve is tested by checking for tongue deviation.
B. This action tests the facial nerve
C. This action tests the trigeminal nerve
D. This action tests the spinal accessory nerve
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Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
Explanation
At 1000, when the nurse enters the client's room and the client is experiencing an aura followed by generalized jerking contractions of arms and legs, the first action the nurse should take is to ensure the client's safety. This includes removing any potential hazards from the immediate vicinity, such as pillows that could obstruct the airway or cause suffocation.
The next critical action is to turn the client to their side, which helps maintain an open airway, allows for any secretions to drain, and reduces the risk of aspiration should vomiting occur. These steps are vital in managing a seizure and are part of the standard care procedures to protect the client during and after a seizure episode.
Correct Answer is A
Explanation
A. Severe wheezing indicates a potential allergic reaction or anaphylaxis to the IV antibiotics, which requires immediate intervention. It can compromise the client's respiratory function and may lead to respiratory arrest if not promptly addressed.
B. Rhinitis, or inflammation of the nasal passages, is not typically associated with IV antibiotic administration and is not a life-threatening emergency.
C. Small, raised vesicles over the body may indicate a rash or allergic reaction, but unless accompanied by other severe symptoms such as difficulty breathing or systemic signs of anaphylaxis, it does not require immediate reporting.
D. Itching of the skin may indicate a mild allergic reaction, but unless accompanied by more severe symptoms, it does not require immediate reporting.
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