Nokea
The nurse educator is reviewing the assessment of cranial nerves. What should the educator identify as the specific instances when cranial nerves should be assessed? Select all that apply.
- A. When a neurogenic bladder develops
- B. When level of consciousness is decreased
- C. With brain stem pathology
- D. In the presence of peripheral nervous system disease
- E. When a spinal reflex is interrupted
Correct Answer: B,C,D
Rationale: Cranial nerve assessment is indicated for altered consciousness, brain stem issues, or peripheral nervous system disease. Neurogenic bladder and spinal reflexes involve spinal, not cranial, nerves.
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A 72-year-old man has been brought to his primary care provider by his daughter, who claims that he has been experiencing uncharacteristic lapses in memory. What principle should underlie the nurses assessment and management of this patient?
- A. Loss of short-term memory is normal in older adults, but loss of long-term memory is pathologic.
- B. Lapses in memory in older adults are considered benign unless they have negative consequences.
- C. Gradual increases in confusion accompany the aging process.
- D. Thorough assessment is necessary because changes in cognition are always considered to be pathologic.
Correct Answer: D
Rationale: Cognitive changes in older adults are not assumed normal and require thorough assessment to rule out pathology like dementia. Memory and judgment typically remain intact with aging.
The nursing students are learning how to assess function of cranial nerve VIII. To assess the function of cranial nerve VIII the students would be correct in completing which of the following assessment techniques?
- A. Have the patient identify familiar odors with the eyes closed.
- B. Assess papillary reflex.
- C. Utilize the Snellen chart.
- D. Test for air and bone conduction (Rinne test).
Correct Answer: D
Rationale: The Rinne test assesses hearing, a function of cranial nerve VIII. Odor identification tests cranial nerve I, pupillary reflex tests III, IV, and VI, and the Snellen chart tests II.
The physician has ordered a somatosensory evoked responses (SERs) test for a patient for whom the nurse is caring. The nurse is justified in suspecting that this patient may have a history of what type of neurologic disorder?
- A. Hypothalamic disorder
- B. Demyelinating disease
- C. Brainstem deficit
- D. Diabetic neuropathy
Correct Answer: B
Rationale: SERs detect slowed nerve conduction, common in demyelinating diseases like multiple sclerosis. They are not used for hypothalamic, brainstem, or diabetic neuropathy diagnoses.
An elderly patient is being discharged home. The patient lives alone and has atrophy of his olfactory organs. The nurse tells the patients family that it is essential that the patient have what installed in the home?
- A. Grab bars
- B. Nonslip mats
- C. Baseboard heaters
- D. A smoke detector
Correct Answer: D
Rationale: Olfactory atrophy impairs smell, increasing the risk of missing smoke or gas. A smoke detector is critical for safety. Grab bars and mats address mobility, and heaters are unrelated to olfactory deficits.
The nurse caring for an 80 year-old patient knows that she has a pre-existing history of dulled tactile sensation. The nurse should first consider what possible cause for this patients diminished tactile sensation?
- A. Damage to cranial nerve VIII
- B. Adverse medication effects
- C. Age-related neurologic changes
- D. An undiagnosed cerebrovascular accident in early adulthood
Correct Answer: C
Rationale: Aging reduces sensory receptor density, dulling tactile sensation. Cranial nerve VIII affects hearing, medications may cause other effects, and an old CVA is less likely without evidence.