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Neurological testing of the patient indicates impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). Which of the following actions should the nurse include in the plan of care?
- A. Insert an oral airway.
- B. Withhold oral fluid or foods.
- C. Provide highly seasoned foods.
- D. Apply artificial tears every hour.
Correct Answer: B
Rationale: The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex; a patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve.
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When caring for a patient who has had cerebral angiography, which of the following nursing actions should be included in the plan of care?
- A. Ask about headache and photophobia.
- B. Keep patient NPO until gag reflex returns.
- C. Check pulse and blood pressure frequently.
- D. Assess orientation to person, place, and time.
Correct Answer: C
Rationale: Since a catheter is inserted into an artery (such as the femoral artery) during cerebral angiography, the nurse should assess for bleeding after this procedure. The other nursing assessments are not necessary after angiography.
The nurse is developing a plan of care for a patient with dysfunction of the cerebellum. Which of the following goals of care should the nurse include?
- A. Prevent falls.
- B. Stabilize mood.
- C. Enhance swallowing ability.
- D. Improve short-term memory.
Correct Answer: A
Rationale: Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability.
Which of the following equipment should the nurse obtain to assess vibration sense in a patient who has peripheral nerve dysfunction?
- A. Electrodes
- B. Tuning fork
- C. Reflex hammer
- D. Goniometer
Correct Answer: B
Rationale: Vibration sense is tested by touching the patient with a vibrating tuning fork. The other equipment is needed for testing of pain sensation, reflexes, and joint range of motion.
Which of the following actions should the nurse implement to assess the functioning of the trigeminal and facial nerves (CN V and VII) in a patient?
- A. Apply a cotton wisp strand to the cornea.
- B. Have the patient read a magazine or book.
- C. Shine a bright light into the patient's pupil.
- D. Check for unilateral drooping of the eyelids.
Correct Answer: A
Rationale: The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to check function of the oculomotor nerve.
A patient has a lesion that affects lower motor neurons. During assessment of the patient's lower extremities, which of the following findings should the nurse expect?
- A. Spasticity
- B. Flaccidity
- C. Loss of sensation
- D. Hyperactive reflexes
Correct Answer: B
Rationale: Because the cell bodies of lower motor neurons are directly affected, a lesion results in flaccidity, loss of muscle tone, and decreased reflexes. Spasticity and hyperactive reflexes are associated with upper motor neuron lesions. Loss of sensation is related to sensory nerve damage, not motor neuron lesions.