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:
"I can drink vegetable juice with a meal."
Limiting sodium intake is a crucial part of managing heart failure, as excess sodium can lead to fluid retention and exacerbation of symptoms. Among the options provided, drinking vegetable juice with a meal is the one that suggests the client understands the need to limit sodium intake. Fresh vegetable juice typically has lower sodium content compared to other options, and incorporating it into meals can help the client manage their sodium intake.
Choice B Reason:
"I can have mayonnaise on my sandwiches." - Mayonnaise is often high in sodium and is not typically recommended in a low-sodium diet.
Choice C Reason:
"I can season my foods with garlic and onion salts." - Garlic and onion salts are often high in sodium. It's better to use fresh herbs and spices for seasoning.
Choice D Reason:
"I can have a frozen fruit juice bar for dessert." - Frozen fruit juice bars might contain added sugars or high sodium content. It's important to check the nutrition label for sodium content before consuming such items.
Correct Answer is D
Explanation
Choice A reason:
WBC count 8,400/mm3 is not appropriate. This white blood cell count is within the normal range and is not a cause for concern.
Choice B reason:
Serosanguineous exudate noted on dressing change is not appropriate. Serosanguineous drainage is a normal finding in the early stages of wound healing and is expected after surgery.
Choice C reason:
Reports pain of 4 on a scale from 0 to 10 when coughing is not appropriate. A pain level of 4 out of 10 with coughing is a common and expected finding following an appendectomy. It's important for the nurse to assess and manage pain, but this is not an urgent concern.
Choice D reason:
Haemoglobin 10 mg/dL is appropriate. Haemoglobin level of 10 mg/dL indicates a low level of haemoglobin, which might suggest anaemia or blood loss. Reporting this finding to the provider is important as it could indicate a need for further evaluation or intervention.
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