Chapter 20 Osborn, Medical-Surgical Nursing, 2e

Question 1 Type: MCSA When assessing the patient’s cognitive function, the nurse would evaluate which parameter? 1. Ability to smell items placed under the nose while eyes are closed 2. Orientation to time, place, and person, and ability to recall recent and past events 3. Ability to walk with a smooth, steady gait 4. Level of consciousness Correct Answer: 2 Rationale 1: This assessment method is used to test for cranial nerve 1, the olfactory nerve. Rationale 2: Orientation to time, place, and person and ability to recall recent and past events is part of cognitive ability. Rationale 3: Gait is not reflective of cognitive ability. Rationale 4: Level of consciousness is not reflective of cognitive ability. Global Rationale:Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20-1 Question 2 Type: MCSA When testing cranial nerve XI (spinal accessory), the nurse should ask the patient to perform which activity? 1. Shrug the shoulders and turn the head against resistance. 2. Stick out the tongue and move it from side to side. 3. Taste foods and distinguish sweet from sour. 4. Identify smells correctly with one side of the nares blocked. Correct Answer: 1 Rationale 1: Cranial nerve XI, the spinal accessory nerve, is tested by asking the patient to shrug the shoulders and turn the head against resistance. Rationale 2: Cranial nerve XII, the hypoglossal nerve, is tested by asking the patient to stick out the tongue and move it from side to side. Rationale 3: Cranial nerve VII, the facial nerve, is tested by asking the patient to distinguish between different tastes. Rationale 4: Cranial nerve I, the olfactory nerve, is tested by having the patient identify smells correctly with one side of the nose blocked. Global Rationale:Cognitive Level: Applying