Nokea
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.
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The nurse is admitting a patient to the unit who is diagnosed with a lower motor neuron lesion. What entry in the patients electronic record is most consistent with this diagnosis?
- A. Patient exhibits increased muscle tone.
- B. Patient demonstrates normal muscle structure with no evidence of atrophy.
- C. Patient demonstrates hyperactive deep tendon reflexes.
- D. Patient demonstrates an absence of deep tendon reflexes.
Correct Answer: D
Rationale: Lower motor neuron lesions result in flaccid paralysis, muscle atrophy, and absent deep tendon reflexes due to disrupted nerve supply to muscles. Increased tone and hyperactive reflexes indicate upper motor neuron issues.
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.
When caring for a patient with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would the nurse use to elicit a response from cranial nerve VII?
- A. Palpate trapezius muscle while patient shrugs should against resistance.
- B. Administer the whisper or watch-tick test.
- C. Observe for facial movement symmetry, such as a smile.
- D. Note any hoarseness in the patients voice.
Correct Answer: C
Rationale: Cranial nerve VII (facial) is assessed by observing facial symmetry during movements like smiling. Trapezius testing assesses XI, whisper tests VIII, and hoarseness tests X.
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.
A trauma patient in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death?
- A. Magnetic resonance imaging (MRI)
- B. Electroencephalography (EEG)
- C. Electromyelography (EMG)
- D. Computed tomography (CT)
Correct Answer: B
Rationale: EEG confirms brain death by showing no electrical activity. MRI, CT, and EMG are not standard for this determination.