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).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
A WBC count of 20,000/mm3 indicates infection and inflammation, which is expected in osteomyelitis. Long-term IV antibiotic therapy is a common treatment for osteomyelitis and may require a referral to avoid peripherl thrombophlebitis. Furosemide is a diuretic that may be prescribed for clients who have fluid retention or hypertension, which are not related to osteomyelitis. A HbA1c of 6% indicates good glycemic control for a client with type 2 diabetes mellitus, which can help prevent complications and infections.
Correct Answer is A
Explanation
The ABG results show a low pH (acidosis), a high PaCO2 (respiratory component), and a normal HCO3 (metabolic component). This indicates respiratory acidosis, which is caused by hypoventilation and retention of carbon dioxide.
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