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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Request an interpreter during the initial assessment involves requesting the assistance of a qualified sign language interpreter to facilitate communication between the nurse and the client who is deaf. This is generally considered the most appropriate and effective option for ensuring accurate and clear communication during the admission process.
A. It may not be feasible for the nurse to become fluent in sign language immediately, learning commonly used signs can help establish basic communication and demonstrate respect for the client's communication needs. However, relying solely on this option may not be sufficient for complex communication needs or during emergencies.
B. Obtaining a board that uses colored pictures as communication may not fully address the client's needs, especially if they primarily use sign language. This option might be useful as a supplementary aid but may not be the most effective method for initial communication.
D. While having a family member present can be helpful, especially if they are proficient in sign language, it may not always be feasible or reliable. Additionally, relying on family members for interpretation can compromise the client's privacy and confidentiality, as well as potentially introduce biases or misunderstandings in communication.
Correct Answer is C
Explanation
A. Bladder spasms are a common postoperative complication after TURP, and they are typically associated with the irritation of the bladder wall. Cold compresses may be helpful for reducing muscle spasms or swelling in other situations, but they are not typically effective for relieving bladder spasms specifically.
B. Securing the urinary catheter is important to prevent dislodgement and ensure proper drainage. However, securing it to the upper left quadrant of the abdomen is not a standard practice.
C. The appropriate response is often to irrigate the catheter to relieve the obstruction and restore normal flow. While 0.9% sodium chloride (normal saline) is typically used for irrigation, the term "intermittent" refers to manually irrigating the catheter at intervals to flush out any blockages, which is an appropriate approach when there is a concern about obstruction.
D. Encouraging the client to urinate every 2 hours is not feasible or necessary in this situation.
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