During an assessment of a patient's cranial nerves, the nurse states, Please stick out your tongue. The nurse observes that the tongue deviates markedly to the right side. What is the patient most likely exhibiting?
1. abnormal hypoglossal nerve response
2. first cranial nerve (CN I) damage
3. sluggish oculomotor response
4. absence of the Homans sign
Question 2A patient reports hearing noises when alone in a quiet room. What action should the nurse take?
1. make sure the patient is referred to a psychiatrist
2. document that the patient has a mental illness
3. ask if the patient experiences any visual disturbances
4. explain to the patient that this is not unusual
Question 3The nurse observes signs that a patient may be experiencing dysfunction related to the acoustic nerve (CN VIII). Which actions should the nurse take to minimize the patient's risk for injury?
Select all that apply.
1. identifying the patient's fall risk category
2. assessing the patient's gag reflex prior to offering food or liquids
3. assisting the patient with bedside sitting or toileting
4. assessing the patient's vision using a Snellen chart
5. placing a red falls risk bracelet on the patient's arm
Question 4A patient experiencing extreme emotional stress is observed to be exhibiting both tachycardia and tachypnea. Which component of the patient's nervous system is responsible for normalizing the patient's response?
1. central
2. peripheral
3. sympathetic
4. parasympathetic
Question 5During a health history the nurse plans to assess the functioning of a patient's central nervous system (CNS). Which question should the nurse ask to assess this function?
1. Do you get dizzy when moving from a sitting to standing position?
2. Do you have difficulty adjusting to changes in temperature?
3. Do you have difficulty falling asleep in the evening?
4. Have you had any weight loss?
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