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 B
Explanation
Choice A Reason:
Administer a sedative medication is incorrect. Administering a sedative can help the client feel more comfortable during the procedure, but ensuring allergy safety comes first.
Choice B Reason:
Determine whether the client has an allergy to local anaesthetics is correct. The priority intervention for the nurse is to determine whether the client has an allergy to local anaesthetics. Local anaesthetics are typically used to numb the area before a thoracentesis, and ensuring the safety of the client is essential. An allergy to local anaesthetics can result in serious adverse reactions, so it's crucial to identify any allergies before proceeding with the procedure.
Choice C Reason:
Describe the sensations the client will feel during the procedure is incorrect. Providing information about the sensations is important for client education and comfort, but verifying allergies is more critical.
Choice D Reason:
Reinforce the importance of lying still during the procedure - Encouraging the client to lie still is important for the procedure's success and client safety, but confirming allergies takes priority.
Correct Answer is B
Explanation
Choice A reason:
Checking the client's vital signs is not appropriate. Checking vital signs is important to assess the severity of the reaction and monitor the client's overall condition.
Choice B reason:
Stopping the infusion is appropriate. Stopping the infusion is crucial to prevent further administration of the blood product that might be causing the adverse reaction. Once the infusion is stopped, the nurse can assess the client's condition more thoroughly and determine the appropriate steps to take next.
Choice C reason:
Collecting a urine sample is not appropriate. While urine sample collection may be important to assess for hemolysis (breakdown of red blood cells), it's not the first action to take. Stopping the infusion and assessing the client's vital signs are more immediate priorities.
Choice D reason:
Administering oxygen to the client is not appropriate. Providing oxygen might be necessary if the client is experiencing respiratory distress, but it's not the first action to take. Stopping the infusion and assessing the situation before providing additional interventions.
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