Exam 3 study

Cranial Nerve 9: Glossopharyngeal

Mixed nerve that functions for swallowing and taste (taste buds on tongue) (loss of the pharyngeal would make for poor eating)

ICP normal range

0-15

Cranial Nerve 8: Vestibulocochlear

Sensory nerve that functions for balance and equilibrium.

Cranial Nerve 1: Olfactory

sensory, smell

Cranial Nerve 10: Vagus

M&S; motor- swallowing, vocal cord movement, innervates carotids and aortic bodies sensory- sensation of pharynx/larynx

Cranial Nerve 7: Facial

M&S; sensory- anterior 2/3 taste of tongue motor- facial muscle movement

Cranial Nerve 3: Oculomotor

M; up, down, medial eye muscle movements and papillary constriction

The nurse is assessing the client who is receiving continuous Ambulatory peritoneal dialysis. Which of the following findings should the nurse report to the provider?

Potassium 3.0 mEq/L Dialysis remove fluid, waste products, and electrolytes from the blood and can cause hypokalemia

Cranial Nerve 5: Trigeminal

SENSORY: FACE SENSATION, SHARP OR DULL E.G. COTTON BALL OR PIN ON FACE POSITIVE FOR INABILITY TO DIFFERENTIATE SHARP OR DULL MOTOR: MUSCLES OF MASTICATION E.G. PROTRUSION, RETRUSION, LATERAL DEVIATION POSITIVE FOR IMPAIRED ABILITY TO MOVE MANDIBLE

Monroe-Kellie Doctrine

When one of the contents of the skull (ie blood, brain, CSF) increases, another must decrease to compensate and maintain normal ICP

A nurse is caring for a client who is in balanced suspension skeletal traction and reports intermittent muscle spasms. Which of the following actions should the nurse take first?

check the position of the weights and ropes The first action the nurse should take when using the nursing process is to assess the client. The nurse should first check the position of the weights and ropes to investigate the cause of the muscle spasms. The weights might be too heavy, or the nurse might need to realign the client.

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider?

clear drainage from nose Clear drainage from the nose indicates that cerebrospinal fluid is leaking from the skull fracture. This places the client at risk for meningeal infection because micro-organisms have access to the cranium through the nose and the tear in the dura. The nurse should report this finding to the provider.

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect?

impulsive behavior The nurse should expect clients who had a right hemispheric stroke to demonstrate impulsive behavior, poor judgment, and lack of awareness of neurologic deficits.

Cranial Nerve 6: Abducens

lateral eye movement

A nurse is planning care for a client who has. closed traumatic brain injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurses priority?

maintain a PaCO2 of approximately 35 mmHg The greatest risk to this client is injury from increased intracranial pressure. Therefore, the nurse's priority intervention is to maintain the PaCO2 at 35 to 38 mm Hg to prevent hypercarbia and subsequent vasodilation that can lead to an increase in intracranial pressure.

Cranial nerve 11: Accessory Nerve

motor fibers to neck and upper back

A nurse in an emergency department is assessing a client who reports sudden, severe eye pain with blurry vision. The provider determines that the client has primary angle-closure glaucoma. Which of the following medications should the nurse expect to administer?

osmotic diuretics via IV bolus The nurse should expect to administer prescribed osmotic diuretics, such as mannitol, to reduce intraocular pressure and prevent damage to the eye.

A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt to the hemianopsia, the nurse should take which of the following actions?

remind the client to look consciously at both sides of their meal tray Clients who have right-sided homonymous hemianopsia have lost the right visual field of both eyes and might only eat the food they are able to see on the left half of the meal tray. Therefore, the nurse should remind the client to look at both sides of his meal tray to help compensate for the visual loss.

A nurse is assessing a client who has a head injury following a motor-vehicle crash. The nurse should identify that which of the following findings indicates increasing intracranial pressure?

restlessness Behavioral changes, such as restlessness and irritability, are early manifestations of increased intracranial pressure.

Cranial Nerve 2: Optic Nerve

sensory, vision

A nurse in an emergency department is caring for a client who suddenly lost consciousness and fell while at home. The provider determines that the client had an embolic stroke. Which of the following medications should the nurse expect to adminster?

tissue plasminogen activator Tissue plasminogen activator is a thrombolytic agent that should dissolve the blood clot that caused the stroke.

hypoglossal nerve 12

tongue movements for speech, food manipulation and swallowing

Cranial Nerve 4: Trochlear

Motor nerve that moves the eyeball

a nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition?

stroke the client's inner thigh The nurse should stimulate micturition by stroking the client's inner thigh. Other techniques include pinching the skin above the groin and providing digital anal stimulation.

A nurse is assessing a client who is quadriplegic following a cervical fracture at vertebral level C5. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mmHg. Which of the following actions should the nurse take first?

elevated the head of the client's bed These assessment findings indicate that the client is experiencing autonomic dysreflexia and is at greatest risk for possible rupture of a cerebral vessel or increased intracranial pressure. The first action the nurse should take is to move the client from a supine to an upright position, which will result in rapid postural hypotension.

A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to take?

ensure that the client lies flat for up to 12 hr The client should lie flat for up to 12 hr to prevent cerebrospinal fluid leakage from the puncture site, which can cause a headache.