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

Answer and Explanation

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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Correct Answer is B

Explanation

Palpating the dorsalis pedis pulse is an essential action to monitor for adequate circulation and perfusion in an extremity with an external fixator, which is a device that stabilizes and aligns fractured bones with metal pins and rods outside of the skin. The other options are incorrect because they could cause complications such as edema, infection, or malalignment.

A. Pupillary dilation B. Decorticate posturing C. Altered level of consciousness D. Cheyne-Stokes respirations

Correct Answer is C

Explanation

Altered level of consciousness (LOC) is the earliest and most sensitive indicator of increased ICP, which can result from brain injury, tumor, hemorrhage, infection, or edema.

The nurse should monitor the client's LOC using the Glasgow Coma Scale (GCS) and report any changes or deterioration to the provider. Pupillary dilation, decorticate posturing, and Cheyne-Stokes respirations are later signs of increased ICP that indicate brainstem compression and herniation, which are life-threatening emergencies.

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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

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