A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?
Inability to smell
Loss of peripheral vision
Disequilibrium with movement
Deviation of the tongue from midline
The Correct Answer is C
C. The vestibulocochlear nerve is responsible for both the vestibular function and the cochlear function. Impaired function of the vestibulocochlear nerve could result in symptoms related to vestibular dysfunction, such as disequilibrium (feeling unsteady or off balance) especially with movement.
A. The olfactory nerve (cranial nerve I) is responsible for the sense of smell.
B. Loss of peripheral vision is typically associated with impairment of the optic nerve (cranial nerve II), which is responsible for vision.
D. Deviation of the tongue occurs in injury to the hypoglossal nerve.
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Related Questions
Correct Answer is A
Explanation
A. Neurovascular assessment should be the nurse's priority assessment. Postoperative patients, especially those who have undergone orthopedic surgery such as ORIF of the femur, are at risk for neurovascular compromise due to factors such as positioning during surgery, edema, and postoperative pain.
B. Pain assessment is important for overall patient comfort and well-being, but in the immediate postoperative period following ORIF of the femur, neurovascular assessment takes priority.
C. The Braden scale is used to assess a patient's risk for pressure ulcers. While pressure ulcer risk assessment is important for overall patient care, it is not the priority assessment for a patient who is postoperative following ORIF of the femur.
D. The Morse Fall Risk scale is used to assess a patient's risk for falls. While fall risk assessment is important for patient safety, it is not the priority assessment for a patient who is postoperative following ORIF of the femur.
Correct Answer is B
Explanation
B. Painless vaginal bleeding, especially after sexual intercourse or between menstrual periods, can be an early sign of cervical cancer. This bleeding may occur due to cervical lesions or abnormalities, such as cervical dysplasia or cervical cancer. It is important for individuals to report any abnormal vaginal bleeding to their healthcare provider for further evaluation.
A. Urinary hesitancy, which is difficulty starting urination or a delay in the initiation of the urinary stream, is not typically associated with cervical cancer.
C. Unexplained weight gain is not typically associated with cervical cancer.
D. Frequent diarrhea is not typically associated with cervical cancer.
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