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 C
Explanation
Choice A Reason:
NG tube with suction apparatus should not be recommended. NG tubes and suction are not routine equipment for managing cystic fibrosis. They might be used for other medical conditions, such as digestive issues or nutritional support.
Choice B Reason:
Chest tube with a drainage system should not be recommended -. Chest tubes and drainage systems are used to manage conditions like pneumothorax or pleural effusion, which are not directly related to cystic fibrosis.
Choice C Reason:
A chest physiotherapy (CPT) vest, also known as a high-frequency chest wall oscillation (HFCWO) vest, is commonly used by clients with cystic fibrosis to help clear mucus from the lungs. The vest vibrates at high frequency, loosening the mucus and making it easier for the client to cough it up, thus helping to manage respiratory symptoms and reduce the risk of infections.
Choice D Reason:
A peak flow meter is typically used for clients with asthma to measure the maximum speed of exhalation, which helps in assessing asthma control. While it can be useful for monitoring lung function, it is not specific to cystic fibrosis, where the primary concern is airway clearance rather than peak flow measurement.
Correct Answer is C
Explanation
Choice A reason:
Wound tissue firm to palpation is a false expectation. While firmness can be an indicator of healing in some wounds, it's not a reliable indicator on its own. The appearance and characteristics of the tissue, including granulation tissue, are more significant indicators of healing.
Choice B reason:
Dry brown eschar is a false expectation. Brown eschar is often necrotic tissue that needs to be removed for the wound to heal. Its presence typically suggests a lack of healing progress.
Choice C reason:
Dark red granulation tissue is the correct expectation because it is a sign of healing in a pressure ulcer. Granulation tissue is the new tissue that forms during the healing process, and the dark red color indicates that the tissue is well-vascularized and receiving adequate blood supply, which is essential for healing.
Dark red granulation tissue is a positive sign of wound healing. It indicates that new blood vessels are forming and that the wound is progressing toward the later stages of healing. Granulation tissue is crucial for wound repair and serves as the foundation for new tissue growth.
Choice D reason:
Light yellow exudate is a false expectation. Light yellow exudate is often indicative of infection or non-healing wounds. While some exudate is normal in the healing process, its colour alone doesn't necessarily indicate healing.
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