Questions with 100% Correct
Answers | Latest Update
How should the nurse assess the client's cranial nerve V (trigeminal)?
Ask the client to smile, raise their eyebrows, and puff out their cheeks.
Ask the client to open their mouth against resistance.
Ask the client to say "ah" and observe the upward movement of the soft
palate.
,Ask the client to shrug their shoulders against resistance. - ANSWER
✔✔Ask the client to open their mouth against resistance.
The client is admitted due to altered intracranial regulation. The client
has cranial nerve IX and X dysfunction. What should the nurse do first?
Assist the client to ambulate in the bedside commode.
Withhold oral fluids and food immediately.
Apply antibiotic eye ointment every 4 hours.
Intubate the client immediately and provide them with oxygen. -
ANSWER ✔✔Withhold oral fluids and food immediately.
The client had a positive Romberg test. What is the priority nursing
diagnosis?
Impaired breathing pattern
Powerlessness
Decreased cardiac output
Risk for fall - ANSWER ✔✔Risk for fall
,What is the cerebral perfusion pressure of a client that has a blood
pressure of 180/90 mmHg and an intracranial pressure of 35 mmHg?
95 mmHg
105 mmHg
110 mmHg
85 mmHg - ANSWER ✔✔85 mmHg
What impact does mean arterial pressure have on intracranial
regulation?
High mean arterial pressure may indicate a high intracranial pressure in
a susceptible client.
Low mean arterial pressure could suggest that there is altered
intracranial regulation.
High mean arterial pressure indicates that the intracranial pressure is
low.
High mean arterial pressure means that there is great cerebral
perfusion. - ANSWER ✔✔High mean arterial pressure may indicate a
high intracranial pressure in a susceptible client.
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3
, Review the following nursing diagnoses (left side). Match the correct
nursing action (right side) that addresses each diagnosis.
Pain
Impaired mobility
Altered gas exchange
Impaired airway clearance
Altered cognition
Imbalanced body temperature
Impaired swallowing
Comfort measure, Head of the bed at 30 degrees, Quiet non-stimulating
environment, Temperature control measures, Mobility assistance,
Feeding assistance, Emergency airway equipment available -
ANSWER ✔✔Pain - Comfort measure
Impaired mobility - Mobility assistance Altered gas exchange - Head of
the bed at 30 degrees
Impaired airway clearance -Emergency airway equipment available