Nokea
The nurse is caring for a patient who exhibits abnormal results of the Weber test and Rinne test. The nurse should suspect dysfunction involving what cranial nerve?
- A. Trigeminal
- B. Acoustic
- C. Hypoglossal
- D. Trochlear
Correct Answer: B
Rationale: The Weber and Rinne tests assess hearing, mediated by cranial nerve VIII (acoustic). Trigeminal affects facial sensation, hypoglossal moves the tongue, and trochlear controls eye movement.
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A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, agerelated changes. Of what phenomenon should the nurse be aware?
- A. Hyperactive deep tendon reflexes
- B. Reduction in cerebral blood flow
- C. Increased cerebral metabolism
- D. Hypersensitivity to painful stimuli
Correct Answer: B
Rationale: Aging reduces cerebral blood flow, impacting neurologic function. Deep tendon reflexes may decrease, cerebral metabolism declines, and pain sensitivity often diminishes in older adults.
A trauma patient was admitted to the ICU with a brain injury. The patient had a change in level of consciousness, increased vital signs, and became diaphoretic and agitated. The nurse should recognize which of the following syndromes as the most plausible cause of these symptoms?
- A. Adrenal crisis
- B. Hypothalamic collapse
- C. Sympathetic storm
- D. Cranial nerve deficit
Correct Answer: C
Rationale: Sympathetic storm, triggered by brain injury, causes altered consciousness, elevated vital signs, diaphoresis, and agitation due to sympathetic overstimulation. Other options do not fully explain these symptoms.
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.
The nurse is performing a neurologic assessment of a patient whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the patients level of consciousness (LOC)?
- A. Assess the patients vital signs and correlate these with the patients baselines.
- B. Assess the patients eye opening and response to stimuli.
- C. Document that the patient currently lacks a level of consciousness.
- D. Facilitate diagnostic testing in an effort to obtain objective data.
Correct Answer: B
Rationale: LOC in non-responsive patients is assessed by eye opening and responses to stimuli, per the Glasgow Coma Scale. Vital signs and testing are supplementary, and lack of response doesn't mean no consciousness.
A patient exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most plausible cause of this patients health problem?
- A. Cerebellar dysfunction
- B. A lesion in the pons
- C. Dysfunction of the medulla
- D. A hemorrhage in the midbrain
Correct Answer: A
Rationale: The cerebellum coordinates movement and balance, so dysfunction causes uncoordinated gait. Pons, medulla, and midbrain lesions affect other functions like respiration or eye movement.