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.
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Related Questions
Correct Answer is C
Explanation
Choice A reason:
Hct 42% is not appropriate. This haematocrit value is within the normal range (usually around 36-46% for females and 38-50% for males).
Choice B reason:
WBC count 8,000/mm3 is not appropriate. This white blood cell count is within the normal range (typically around 4,500 to 11,000/mm3).
Choice C reason:
INR of 1.6 An INR (International Normalized Ratio) of 1.6 indicates that the client's blood clotting time is prolonged, which means that they might have a decreased ability to form blood clots. This could pose a significant risk during surgery, as proper blood clotting is important to prevent excessive bleeding. The surgeon needs to be aware of this result to determine if any adjustments to the surgical plan or preoperative medications are necessary to ensure the client's safety.
Choice D reason:
Platelets 95,000/mm3 is not appropriate This platelet count is slightly lower than the normal range (typically around 150,000 to 450,000/mm3), but it might not be low enough to be immediately concerning, especially if the client doesn't have a history of bleeding disorders. However, it's still important for the surgical team to be aware of this value.
Correct Answer is D
Explanation
Choice A reason:
"use my heating pad on a low setting to keep my feet warm". This statement is incorrect. Using a heating pad, especially on a low setting, is not recommended for individuals with PAD. It can lead to burns or skin damage due to reduced sensation in the feet.
Choice B reason:
"rest in my recliner with my feet elevated for about an hour every afternoon" This statement is incorrect. While elevating the feet can help with blood circulation, it's important to avoid prolonged periods of inactivity. Regular physical activity is important for improving circulation.
Choice C reason:
"soak my feet in hot water before trimming my toenails". This statement is incorrect. Soaking feet in hot water can cause burns or damage to the skin for individuals with reduced sensation due to PAD. Trimming toenails should be done carefully and without soaking to prevent injury and infection.
Choice D reason:
"apply a lubricating lotion to the cracked areas on the soles of my feet every morning “This statement is correct. Clients with peripheral arterial disease (PAD) are at risk of reduced blood circulation to the extremities, including the feet. Proper foot care is crucial to prevent complications such as non-healing wounds or infections. Applying a lubricating lotion to cracked areas can help keep the skin moisturized and prevent further complications.
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