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 B

Explanation

Indicates an increased risk of skin breakdown. This is because significant weight loss can lead to muscle wasting and reduced subcutaneous tissue, making the skin more vulnerable.

Bronchodilators, hemoglobin level and oxygen device do not relate directly to skin breakdown

A. "I can take another dose after 2 minutes." B. "I should take this medication as soon as the pain begins." C. "I should chew the tablet before I swallow it." D. "I can put the tablet against my cheek and gum."

Correct Answer is B

Explanation

B. Sublingual nitroglycerin is intended for the immediate relief of angina symptoms. Clients should take the medication as soon as they experience chest pain or discomfort. Prompt administration can help alleviate symptoms and prevent the progression of angina episodes.
A. If the chest pain persists or worsens after taking the first dose of sublingual nitroglycerin, the client can take a second dose after 5 minutes. However, taking another dose after only 2 minutes may increase the risk of hypotension and other adverse effects.
C. Sublingual nitroglycerin tablets are not meant to be chewed or swallowed. Instead, they should be placed under the tongue and allowed to dissolve completely. Chewing or swallowing the tablet can reduce the medication's effectiveness.

D. Sublingual nitroglycerin should be placed under the tongue, not against the cheek or gum.

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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 assessing a female client who has pneumonia. The nurse should identify which of the following findings increases the client's risk of skin breakdown?

Correct Answer is B

Explanation

A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following statements made by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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