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 C
Explanation
Choice A Reason:
Peripheral pulses 2+ bilaterally - This indicates good peripheral circulation and is not typically a concerning finding.
Choice B Reason:
Creatinine 0.8 mg/dL - A creatinine level of 0.8 mg/dL is within the normal range and does not indicate acute kidney failure.
Choice C Reason:
Urine specific gravity 1.045 A urine specific gravity of 1.045 is significantly elevated and could indicate concentrated urine, which might be a concern in a client with acute kidney failure. Elevated specific gravity could suggest dehydration, impaired kidney function, or other kidney-related issues. The nurse should report this finding to the provider for further evaluation and intervention.
Choice D Reason:
Weight gain 1.1 kg (2.4 lb) in 24 hr - While weight gain should be monitored closely in clients with kidney failure, 1.1 kg in 24 hours might not be an immediate concern, depending on the client's overall condition and baseline weight. However, it should still be followed up on in subsequent assessments.
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