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)?
Disequilibrium with movement
Deviation of the tongue from midline
Loss of peripheral vision
mobility to smell
The Correct Answer is A
Choice A reason:
Disequilibrium with movement is correct. The vestibulocochlear nerve (cranial nerve VIII) is responsible for both hearing (cochlear component) and balance (vestibular component). Impaired function of this nerve can result in problems with equilibrium and balance, leading to symptoms such as disequilibrium or vertigo (a sensation of spinning or whirling), especially with movement.
Choice B Reason:
Deviation of the tongue from midline is incorrect. This is related to cranial nerve XII (hypoglossal nerve) and its role in tongue movement and control.
Choice C Reason:
Loss of peripheral vision is incorrect. This is related to cranial nerve II (optic nerve) and its role in vision.
Choice D Reason:
Inability to smell is incorrect. This is related to cranial nerve I (olfactory nerve) and its role in the sense of smell.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Wearing a lead apron when providing client care is appropriate. When caring for a client who is receiving internal radiation therapy, the nurse should take appropriate safety measures to minimize their exposure to radiation. Wearing a lead apron when providing care to the client helps shield the nurse's body from radiation exposure and reduces the risk of harm.
Choice B Reason:
Allowing visitors to hold the client's hand is inappropriate. Visitors should also be educated about radiation safety measures and should not be encouraged to have close contact with the client during internal radiation therapy.
Choice C Reason:
Leaving the door to the client's room open is inappropriate. Closing the door to the client's room can help contain radiation and limit its spread to other areas.
Choice D Reason:
Placing the dosimeter badge on the client's bed is inappropriate. The dosimeter badge should be worn by healthcare personnel to measure their radiation exposure. Placing it on the client's bed does not accurately measure the nurse's exposure and is not the correct use of the badge.
Correct Answer is B
Explanation
Choice A reason:
Listening to the client's bowel sounds should not be implemented. It is important for assessing the gastrointestinal status, but the priority in this situation is to address the potential cardiac complications of hypokalaemia.
Choice B reason:
Initiating cardiac monitoring for the client should be implemented. A serum potassium level of 2.8 mEq/L is significantly low (normal range is typically around 3.5-5.0 mEq/L). Low potassium levels, known as hypokalaemia, can lead to serious cardiac arrhythmias and other complications. Therefore, the nurse should prioritize cardiac monitoring to assess for any potential changes or abnormalities in the client's heart rhythm due to the low potassium levels.
Choice C reason:
Checking the client's hand grasps should not be implemented. It is a test for muscle strength and can be indicative of hypokalaemia, but initiating cardiac monitoring is more critical at this point.
Choice D reason:
Administering an IV potassium drip may be necessary, but initiating cardiac monitoring takes precedence as the first action to ensure the client's heart rhythm is stable before addressing the potassium imbalance.
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