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)?
Deviation of the tongue from midline
Loss of peripheral vision
Disequilibrium with movement
Inability to smell
The Correct Answer is C
The nurse should expect disequilibrium with movement if the client has impaired function of the vestibulocochlear nerve, as this nerve is responsible for hearing and balance. Deviation of the tongue from midline indicates impairment of the hypoglossal nerve (cranial nerve XII), loss of peripheral vision indicates impairment of the optic nerve (cranial nerve II), and inability to smell indicates impairment of the olfactory nerve (cranial nerve I).
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
The nurse should attend to the client who has thrombocytopenia and reports a nosebleed first, as this client has the most urgent problem and is at risk of hemorrhage. Thrombocytopenia is a condition characterized by a low platelet count, which impairs blood clotting and increases bleeding tendencies. The other clients have chronic or stable conditions that require ongoing monitoring and intervention, but are not as urgent as the client with the nosebleed.
Correct Answer is C
Explanation
This is because the most common cause of infusion pump alarms is occlusion or obstruction of the IV line, which can be due to kinking, bending, or compression of the tubing or catheter by the client's arm or body position. By repositioning the client's arm, the nurse can relieve the occlusion and restore the flow of the IV fluid.
This action should be done before checking for other possible causes of alarm, such as redness at the IV site (which could indicate infection or inflammation), loose tubing connections (which could cause leakage or air embolism), or clogged IV catheter (which could require flushing with saline or heparin solution).
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