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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.
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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.
A patient is having a fight or flight response after receiving bad news about his prognosis. What affect will this have on the patients sympathetic nervous system?
- A. Constriction of blood vessels in the heart muscle
- B. Constriction of bronchioles
- C. Increase in the secretion of sweat
- D. Constriction of pupils
Correct Answer: C
Rationale: Sympathetic activation during fight or flight increases sweat secretion, dilates heart muscle vessels, bronchodilates, and dilates pupils.
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.
The nurse has admitted a new patient to the unit. One of the patients admitting orders is for an adrenergic medication. The nurse knows that this medication will have what effect on the circulatory system?
- A. Thin, watery saliva
- B. Increased heart rate
- C. Decreased BP
- D. Constricted bronchioles
Correct Answer: B
Rationale: Adrenergic medications stimulate the sympathetic nervous system, increasing heart rate and force. Thin saliva and decreased BP are parasympathetic effects, while bronchodilation, not constriction, occurs.
The nurse is doing an initial assessment on a patient newly admitted to the unit with a diagnosis of cerebrovascular accident (CVA). The patient has difficulty copying a figure that the nurse has drawn and is diagnosed with visual-receptive aphasia. What brain region is primarily involved in this deficit?
- A. Temporal lobe
- B. Parietal-occipital area
- C. Inferior posterior frontal areas
- D. Posterior frontal area
Correct Answer: B
Rationale: Visual-receptive aphasia, involving difficulty copying figures, is linked to the parietal-occipital area, which integrates visual and spatial processing. Temporal lobe damage affects auditory comprehension, and frontal areas impact expressive speech.