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

The nurse should contact the local Department of Health and Human Services for the client, as this agency may be able to provide assistance with heating costs or other resources for low-income individuals.

Older adults are at increased risk of hypothermia, which is a potentially life-threatening condition that occurs when body temperature drops below 35° C (95° F). Hypothermia can be caused by exposure to cold temperatures, inadequate clothing, poor nutrition, chronic illness, or medication use. Therefore, it is important for the nurse to intervene and help the client maintain a safe and comfortable home environment.

A. Vasovagal bradycardia without syncope B. Complete AV block with rates slower than 40/min C. Sinus tachycardia with rates faster than 80/min D. Asymptomatic second-degree AV block

Correct Answer is B

Explanation

A complete AV block (also called third-degree AV block) is a type of heart block in which there is no electrical communication between the atria and ventricles. This means that the atria and ventricles beat independently of each other, resulting in a slow and irregular pulse. A complete AV block can cause symptoms such as dizziness, fainting, chest pain, shortness of breath, and heart failure.

A permanent pacemaker is a device that sends electrical impulses to the heart to regulate its rhythm and prevent bradycardia (slow heart rate). A permanent pacemaker is indicated for clients with complete AV block and rates slower than 40/min or symptomatic bradycardia.

The other options are not indications for a permanent pacemaker. Vasovagal bradycardia is a temporary drop in heart rate and blood pressure caused by a stimulus that triggers the vagus nerve, such as pain, stress, or straining.

It usually resolves on its own or with simple measures, such as lying down or elevating the legs. Sinus tachycardia is a normal increase in heart rate in response to physical or emotional stress, such as exercise, fever, or anxiety. It usually does not require treatment unless it is caused by an underlying condition or causes symptoms.

Asymptomatic second-degree AV block is a type of heart block in which some of the electrical impulses from the atria are blocked from reaching the ventricles. It may not cause any symptoms or affect the overall heart rate. It may be benign or transient, or it may progress to a more serious type of heart block. It may require monitoring or medication, but not a permanent pacemaker unless it causes symptomatic bradycardia.

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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)?

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Correct Answer is B

Explanation

A nurse is reviewing a client's cardiac monitor for dysrhythmias. Which of the following findings should the nurse identify as an indication for the placement of a permanent pacemaker?

Correct Answer is B

Explanation

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