Skills exam 3

Which part of the client's brain primarily regulates muscle functioning and coordinates movement?

Cerebellum

The nurse asks the client to shrug the shoulders and to turn the head against passive resistance. Which cranial nerve is involved in this action?

Cranial nerve XI

Which condition will the nurse monitor for in a client with interruption of venous return?

Veriscosity

The registered nurse is teaching the student nurse about vascular changes of the skin. Which statement does the nurse use while describing the image shown below?

"These are normal markings"

A client is experiencing a myocardial infarction. What should the nurse identify as the primary cause of the pain experienced by a client with a coronary occlusion?

Heart muscle ischemia

A nurse is caring for a client with a tumor of the cerebellum. What clinical manifestation does the nurse expect the client to exhibit?

Inability to execute coordinated movements

The nurse is caring for a client who has a tumor of the cerebellum. What is the client most likely to exhibit?

Inability to execute smooth movements

A nurse is caring for a 9-year-old child in the postanesthesia care unit after craniotomy for the removal of an astrocytoma. Suddenly the child's right pupil dilates. What is the priority nursing intervention?

Notify the HCP

The nurse assesses for damage to the glossopharyngeal (ninth cranial) and vagus (tenth cranial) nerves. Which action will the nurse ask the client to perform?

Swallow

When assessing a client, the nurse observes that the client cannot close the right eye. Which cranial nerve should the nurse assess further?

Seventh

When assessing a neonate immediately after birth, the nurse observes an inability to close the eyes completely. The nurse also observes drooping of the corner of the neonate's mouth, and the absence of wrinkling of the forehead and nasolabial fold. What does the nurse infer from these findings?

The neonates cranial nerve VII was pressurized during labor

A client has inflammation of the facial nerve, causing facial paralysis on one side. Which diagnosis will the nurse most likely observe written in the medical record?

Bell palsy

Which integumentary finding is related to skin texture?

Character of the surface

A client reports buzzing in the ear for the past 5 days and a decreased ability to hear sounds. After interacting with the client, the nurse finds that the client is receiving long-term aminoglycoside therapy. Which cranial nerve should the nurse suspect to be affected?

Cranial VIII

A client who sustained head injuries is admitted to the hospital. During assessment of cranial nerves, the nurse notices that the client lost the perception of taste, especially in the anterior portion of the tongue. Which cranial nerve might have been injured in this client?

Cranial nerve VII

While assessing a client recovering from a head injury, the nurse notices a loss of movement in the client's tongue while attempting to talk. Which could be the possible reason for the client's condition?

Damage to hypoglossal nerve

What is the nurse assessing when checking the cardinal positions from the image?

Extraocular muscle function

The nurse reviews the diagnostic reports of a client and discovers that the client has an injury to cranial nerve VII. What will the nurse observe upon assessment?

Inhibition of tear production

What assessment findings indicate that an older client is at risk for developing an infection? Select all that apply.

Thin skin Weak cough Sluggish bowel sounds indwelling urinary catheter

Which test helps a primary healthcare provider distinguish between conductive and sensorineural hearing loss?

Weber test