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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Frequent vitals monitoring to allow for early detection of infection. Clients with neutropenia are at increased risk of infections.
B. Indwelling catheter and other devices should be avoided in individuals with neutropenia die to risk of sepsis.
C. Changing the client’s linen is important. However, doing it 3 times a day is not necessary.
D. Clients should be placed in a positive airflow room to prevent contracting infections from infected persons

A. Administer oxygen to the client. B. Collect a urine sample. C. Stop the infusion. D. Check the client's vital signs.

Correct Answer is C

Explanation

C. Suspending the infusion of packed RBCs is essential to prevent further administration of the blood product that may be causing the adverse reaction. Stopping the infusion allows for further assessment and appropriate management of the client's symptoms.
A. The client's symptoms of chills, lower back pain, and nausea suggest a potential transfusion reaction rather than respiratory compromise.
B. Collecting a urine sample may be indicated to assess for hemolysis or kidney injury, which can occur as a result of a transfusion reaction. However, this action can be deferred until after immediate interventions to manage the suspected reaction.
D. While checking the client's vital signs is important in assessing the severity of the reaction and the client's overall condition, it is not the first action to take when a transfusion reaction is suspected.

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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)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who has neutropenia. Which of the following precautions should the nurse take?

Correct Answer is A

Explanation

A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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